Nurse Care Manager

RN Care Manager - Reports to Quality Optimization Nurse Manager
$90,000 - $93,000/year
Full-time, exempt
Pottstown, PA
Benefits:
Competitive base salary, Medical Insurance, Dental and Vision Insurance, PTO Accrual, 401K Company Match, 12 Paid Holidays, Company paid life insurance, Employee Health Reimbursement Program, No PTO needed for employee preventative care appointments, Employee Assistance Program, employee discounts, summer picnic, and much more!
Who we are:
Community Health and Dental Care (CHDC) is a non-profit community health center located in Pottstown, PA. We provide the highest quality health and dental care for our patients by utilizing the latest standards and most advanced technology in a professional atmosphere.
What you will do:
The RN Care Manager manages a panel of CHDC’s complex high-risk patients as referred by the patient’s Provider, under the direction of the patients’ Provider. The primary goals of the RN Care Manager are to help improve patient outcomes, reduce unnecessary Emergency Department utilization, prevent hospitalizations and re-hospitalizations. CHDC provides team-based care, and the RN Care Manager serves as a clinical leader within each assigned Provider’s care team. The RN Care Manager collaborates with healthcare professionals across many disciplines both within and outside CHDC, serves as the first line of contact for patients enrolled in CHDC’s CM Program, and adheres to CHDC’s CM Program and Protocol.
Duties include but are not limited to:

• Manage a panel of patients enrolled in CHDC’s CM program
• Document and maintain patient care plans in NextGen using the OSIS Patient Centered Medical Home (PCMH) CM form and reflecting overall treatment goals established by Provider
• Assess patients’ physical, cognitive, psychosocial, functional, and environmental status and identifies barriers to care and achieving desired health outcomes
• Refer patient to internal staff/resources and external services/agencies to address/eliminate barriers to care
• Assist patients in prioritizing follow up care and setting realistic treatment goals, considering each patient’s unique situation.
• For patients enrolled in CHDC’s CM Program, serve as their “first point of contact” and provide “between visit” care to support patients in meeting care priorities
• Outreach to enrolled patients, and/or their caregivers, at least once a month and more often, as needed
• Provide ongoing education and reinforcement regarding care priorities, disease self-management, medications, diagnostics, referrals, diet, lifestyle, navigating the healthcare system, etc.
• Promote preventive care by reviewing health maintenance care gaps that are due, including cancer and other screenings, immunizations, etc.
• Assist in closing care gaps for enrolled patients by regularly reviewing Care Guidelines in NextGen, generating orders, assisting in gathering records, completing orders, as needed
• Update Provider and other care team members between office visits as needed.
• Lead monthly care team meetings (MA, RN, Provider, and others as needed) by providing updates on the enrolled patients, their priorities, and current status.
• Collaborate with interdisciplinary team of healthcare professionals and other office staff, including schedulers, patient service representatives, medical assistants, behavioral health consultants, phlebotomists, pharmacy/dispensary staff, dental staff, physical therapists, optical staff, podiatrists, addiction specialists, etc.
• Assist with the development of policies, protocols, workflows, and standing orders as needed
• Assist with nurse triage, portal messages, and clinical task inbox
• Other duties as assigned

• Full unrestricted RN license in the State of Pennsylvania.
• Minimum 3-5 years clinical experience in any of these areas: acute care, home health, medical office management, managed care organization
• Medical office experience preferred, especially working collaboratively with providers, patients, and families to identify care priorities and develop realistic goals for achieving optimal health outcomes and helping to close identified care gaps.