Care Management RN bei COPC

The Care Manager, RN manages care for high risk, chronically and acutely ill patients by collaborating with the Comprehensive Care team to monitor care and treatment of patients. This position includes coordinating, facilitating, monitoring, and evaluating interventions to achieve desired outcomes. Responsibilities include coordinating with Physicians and functioning as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory, and post-acute care settings. The Care Manager, RN ensures continuity of care through defined, evidence-based methods, including medication reconciliation, self-management plan, engagement of family and caregivers, health education and referrals. This position collaborates with other care team members to address gaps in care. This position promotes improved clinical outcomes and patient satisfaction, while demonstrating efficient use of resources.

 This position will support our Team 2, which serves East Columbus and counties contiguous with eastern Franklin County. The role will focus on managing patients with chronic, complex medical conditions who may need frequent contacts and goals of care conversations. The ideal candidate will have experience in hospice and case management.

Monday - Friday 8am - 5pm
Full-Time/Full Benefits eligible
Westerville, OH

 POSITION(S) SUPERVISED: N/A

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Participate in taking care of high risk, chronically or acutely ill patients.
• Perform complete assessment of patient's current health status, including barriers to achieving optimal health, and available Identify potential gaps in care based on the assessment.
• Participate in the development and creation of an initial plan of care and self-management plan that highlights potential opportunities for improving clinical outcomes and/or utilization patterns. Collaborate with care team, patients, and caregivers to achieve plan of care outcomes and improve patient outcomes.
• Facilitate and monitor the developed plan of care for patients. Work with Comprehensive Care team to manage caseloads.
• Coordinate patient/family/caregiver participation in plan of care and self- Coordinate patient education to achieve plan of care using evidence-based methods.
• Perform Face-to-Face visits as necessary including home, office, and skilled rehab facility settings. Evaluate barriers to attainment of self-management goals and develop strategies to
• Provide ongoing feedback to patient primary care team through regular communication.
• Work in collaboration with inpatient, ambulatory, and community partners to facilitate continuity of
• Facilitate referrals to other disciplines, COPC resources, or community-based programs to improve patient
• Communicate with patients via phone calls or during scheduled home visits promptly. Conduct end-of-life discussions with patient/ family, as
• Document in the medical record and designated case management tool to accurately  reflect collaborative care planning, interventions and evaluation against defined targets and

SECTION IV:  QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Experience, Education, Licensures & Certifications

Required: 5 or more years of clinical and case management experience in a hospital, home health/hospice, or managed care setting

Required: Active Ohio RN license

Required: Active Ohio driver’s license with the ability to travel throughout  COPC’s service area.

Preferred: CCM certification; Bachelor's degree in nursing

1. Knowledge, Skills & Abilities

• Must be able to perform any clinical or clerical duty as assigned skillfully.
• Must demonstrate the ability to handle stressful situations appropriately.
• Must be able to work flexible hours as needed.
• Must demonstrate ability to manage case load and document progress in a timely way as outlined by the care program assigned to each patient.
• Must maintain patient confidentiality.
• Must demonstrate a proficient driving record and up to date auto insurance as travel to visit patients is necessary.
• Knowledge of chronic and acute disease states in adults
• Knowledge of common medications used in a primary care setting including indications, dosages, and side effects.
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management, and quality improvement.
• Proficient in computer software and usage including Microsoft Outlook and Microsoft Excel.
• Strong analytical, organizational, and time management skills.
• Ability to work independently and within a team environment with minimum supervision.
• Ability to demonstrate work toward the progress of patient-centered goals.
• Ability to develop and maintain rapport among health care professionals within individual COPC practices.
• Ability to adapt to changing environment.
• Ability to administer IM medication
• Ability to perform straight or indwelling catheter procedures, blood draw, nebulizer treatment, etc. as necessary
• Ability to provide same day or next day Home Visit’s for assessment as needed (ie., lab specimen collection, education, and treatment plans adjustments with collaboration providers.
• Excellent written and verbal communication skills; ability to communicate effectively in stressful situations.
• Self-disciplined, energetic, passionate, and innovative.
• Decision making/problem solving skills.
• Critical and ‘systems' thinker.
• Strong attention to detail.
• Training/teaching skills.
• Demonstrate awareness and ability to work alongside diverse cultures and patient populations.
• Commitment to customer service.

 Office Culture 

All our staff are expected to remain actively engaged in practice changes and updates.  

COPC prides itself on fostering an environment that respects each employee, regardless of title or background. Collaboration between our teams is paramount in providing the best care for our patients and each other.  Our staff are solution-minded and agree to be available and willing to accept all reasonable requests intended for the benefit of any patient on our service.  We are committed to a culture of innovative healthcare, kindness, and mindful service.