Job Description

Definition:

The Nurse Care Manager works collaboratively with the providers and clinical team to support patients with chronic conditions and complex needs. The Nurse Care Manager delivers quality healthcare and practices according to guidelines and protocols established by the Chief Medical Officer. The Nurse Care Manager works especially closely with the Medical Assistants to identify patients who are considered overdue and out of the range for clinical care goals. The Nurse Care Manager supports the goals and clinical measures of DePaul Community Health Centers. The Nurse Care Manager may be assigned to a primary location and could be asked to support other locations as needed.

Qualifications:

The Nurse Care Manager will possess a clinical base and the experience and desire to work in a holistic health care environment, serving the under-insured and uninsured.



The candidate must have excellent communication skills, including verbal and written. Should be team-oriented with the ability to promote positive and productive communication with all clinic and administrative staff. The Nurse Care Manager should be flexible and organized in a diverse environment.



The candidate must hold a current, unrestricted license to practice as a Registered Professional Nurse in the State of Louisiana, a valid Louisiana driving license (or identification), and current CPR certification.



The candidate should possess a baccalaureate degree from a university or college with a program in nursing accredited by the NLN. Experience in a generalized public health care setting, at least two (2) years, and Care management skills are desired.



Must be knowledgeable of current word processing software, Excel, Microsoft Office, Internet functions, and know how to use the computer.

Duties and Responsibilities:

Is knowledgeable of and applies the Mission and Values of the DePaul Community Health Centers.


Collaborates with clinic staff and all department leaders in providing optimal and state of the art patient care by responding to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c >8, elevated LDL, elevated Blood Pressure - greater than 140/90, Asthmatic patients in poor control, patients on anticoagulation therapy).


Assumes an active role in patient education, self-management goal setting, and coaching. Helps the patient identify learning needs and provides patient teaching and resources according to chronic conditions.


Provides intensive care management to high-risk complex patients according to established protocols and algorithms.


Monitors patients on anticoagulation therapy according to protocols used at DCHC.


Completes medication reconciliation with patients during patient encounters.


Tracks abnormal cancer screens and ensures the next step has been completed. Submits reports within the indicated timeframes.


Initiates and completes Home Health Referrals as ordered by the providers.


Assesses patients' readiness to change and provides patients and family Completes new hire Care Manager orientation program and participates in ongoing training for the role of Care Manager by attending webinars, workshops, seminars, online self-directed training, and quarterly Care Manager meetings. ily with community resources to support change.


Documents complete and accurate Care Management interventions (e.g. telephone calls, face to face encounters, lab results) in the Electronic Health Record using the CM documentation tool and communicates the patient's progress to the appropriate provider.


Assists with the orientation of new hires.


Attends clinical care and General Staff meetings as scheduled.


Participates in the implementation and evaluation of clinical programs.


Supports the policies and procedures of the DePaul Community Health Centers. Participates in the review of agency policies as requested.


Maintains good and punctual attendance.


Promotes positive and productive communication with clinic staff.


Utilizes established channels of communication and proper lines of authority for problem-solving and communication.


Assists in the documentation of incidents and untoward events; participates in safety programs and disaster drills.


Performs other duties as requested by the supervisor and Medical Director.


Maintains HIPAA compliance guidelines.


Completes new hire Care Manager orientation program and participates in ongoing training for the role of Care Manager by attending webinars, workshops, seminars, online self-directed training, and quarterly Care Manager meetings.

Working Conditions

The candidate must be able to sit or stand for long periods, use the computer, and lift light equipment.