Primary Care Clinic-RN Care Manager

JOB REQUIREMENTS: Provide a coordinated, strategic approach to detect
early, and manage effectively, the chronically ill patient population.
Implement an effective internal tracking system for identified patients.
Coach patients/families toward successful self-management of their
chronic disease. Utilize tools and documents that support a guided care
process, collaborate with patient/family toward an effective plan of
care. Assess patient and familys unmet health and social needs.
Provide effective communications to improve health literacy. Develop a
care plan based on mutual goals with patient, family, and providers
emergency plan, medical summary, and ongoing action plan, as
appropriate. o Monitor patient adherence to plan of care and progress
toward goals in a timely fashion, and facilitate changes as needed.
Create ongoing processes for patients/families to determine and request
the level of care coordination support they desire overtime. Promote
healthy behaviors in all populations, and ensure navigation assistance
with community resources. Facilitate patient access to appropriate
medical and specialty providers as well as other care coordination team
support specialists, (i.e. Dietitian). Cultivate and support primary
care and subspecialty co-management with timely communication, inquiry,
follow-up, and integration of information into the care plan regarding
transitions-in-care, and referrals. Serve as the contact-point,
advocate, and informational resource for patient, family, care team,
payers, and community resources. Ensure effective tracking of test
results, medication management, and adherence to follow-up appointments.
Develop systems to prevent errors (e.g. effective medication
reconciliation and shared medical records). Facilitate attended meetings
between patient, families, care team, payers, and community resources,
as needed. Ability to use office equipment such as telephones,
computers, printers, fax, and scanner. Ability to use medical equipment
such as Blood Pressure, and EKG equipment. OTHER EXPERIENCE
AND QUALIFICATIONS: Previous experience in caring for chronic disease
patients required. 3-5 Years experience in clinical or community
health settings preferred. Previous Care Coordination, Case Management
or Home Health experience preferred. Demonstrates evidence of essential
leadership, communication, education, collaboration, and counseling
skills. Proficient in communication technologies (email, cell phone,
etc.). Efficient organization skills and demonstrates ability to
maintain accurate notes and records. Previous experience with health IT
systems and data reports preferred. Previous experience with mobilizing
community resources, navigating patients through the healthcare
continuum, and working with disparate populations preferred. Ability to
identify and implement appropriate patient communication strategies, and
overcome accessibility barriers, as required. APPLICATION
INSTRUCTIONS: Apply Online:
https://www.lafayettecountywi.org/hr/job-opening/primary-care-clinic-full-time-rn-care-manager