RN Care Manager
Company: SoNE HEALTH
Posted on: May 11, 2022
Job DescriptionSummary of Responsibility:The RN Care Management
(RN CM) is an RN responsible for care management of high-risk
patient populations with complex comorbidities. The RN CM maintains
patient-centered care working with patients and their
families/caregivers in collaboration with physicians and other
health care team members. Standards of practice include care
coordination, collaboration, accountability, advocacy,
professionalism, and resource management. The RN CM practices
comprehensive assessments along the care continuum, working with
patients to meet physical, psychosocial, and/or spiritual needs.
The RN CM uses motivational interviewing skills and knowledge to
empower patients with care goal creation and meeting
self-management action plans toward wellbeing.Essential
- Knowledge of patient care delivered in the ambulatory setting,
valuing the vision, mission, and strategies of Population Health in
offering value-based care by improving patient care, enhancing
patient experiences, reducing healthcare costs, and improving
provider satisfaction for stakeholders.
- Identify and engage appropriate patients for care management
from lists and referrals, in collaboration with team leads
- Ability to execute core care management duties:
- Comprehensive assessment: bio-psycho-social-spiritual
- Collaboration with patient and care team to develop
patient-centered care plan, with particular focus on chronic
disease management, social determinants, transitions of care and
advanced care planning
- Implementation of care plan; Working with clients, family and
friend support networks and health care professionals to put care
plans in place
- Collaboration with community partners, such as VNA agencies,
caregiver programs, DME providers and social service agencies;
- Assessment of goal completion, with transition of patient to
inactive or graduated status as appropriate.
- Educate the patient on their medication conditions and
medications, and build their self-management skills;
- Use motivational interviewing to promote behavioral
- Assess, triage, and rapidly respond to clinical changes that
could lead to the need for emergency services if not intervened
- Knowledge of common chronic/complex medical conditions
presented in the population served with ability to:
- Development and communication (with patient, caregiver and
primary care physician/health care team) of a comprehensive care
plan and patient action plan/goals of care based on evidence-based
best practice for complex illness.
- Pro-active management and follow-up according to care plan that
includes incorporation of self-care and shared decision making in
all aspects of patient care.
- Coordination of skilled care with home care nurse,
communicating home care notifications and authorizations to the
- Coaching patients in the development of self-management goal
setting and behavior change skills for attaining their goals.
- Management and coordination of all transitions in care for
complex patient panel:
- Communicates care plan to all providers in all settings of care
(ED, hospital, rehabilitation facility, nursing home, home care and
- Ensures that relevant providers receive timely clinical data
for care treatment decisions in all settings of care (ED, hospital,
rehabilitation facility, nursing home, home care and specialty
- Directs caregiver support, including ad hoc telephone
- Facilitation of patient and caregiver access to community
resources relevant to patient's needs, including referrals to
transportation programs, Meals on Wheels, senior centers, chore
- Identifies gaps in care and assists with performance
improvement opportunities to close such gaps.
- Attends required meetings and participates in committees as
requested and assists with special projects as needed.
- Cultivates positive relationships with all stakeholders, and
members of the care team.
- Educates patient, family and other health care members on the
role and purpose of Care Coordination, its processes, disease/case
management programs and outcomes and makes referral to appropriate
Care Coordination services as needed.
- Maintains a working knowledge of applicable Federal, State, and
local laws and regulations, Trinity Health's Organizational
Integrity Program, Standards of Conduct, as well as other policies
and procedures in order to ensure adherence in a manner that
reflects honest, ethical, and professional behavior. Other
- Performs other duties as assigned.The duties listed above are
intended only as illustrative of the various types of work that may
be performed. The omission of specific statements of duties does
not exclude them from the position if the work is similar or a
logical assignment to the position.QUALIFICATIONS AND COMPETENCIES:
- RN license required; RN licensure in CT and MA preferred; CCM,
ACMA, or other case management certification preferred
- Bachelor's Degree in nursing preferred
- Three or more years of nursing experience, preferably with at
least one year in care management, care coordination, or nurse
navigation role; or alternatively, in an ambulatory care setting
including telephonic triage
- Knowledge of Medicare and/or Commercial insurance guidelines
pertaining to patient care management in the ambulatory/community
care setting is preferred.
- Excellent organizational skills required, with the ability to
communicate and work collaboratively with all levels of staff,
payors, providers and office staff, and effectively utilizing all
- Must be adaptable to unpredictable situations in a patient care
setting while effectively managing assigned duties with precise
attention-to-detail, accuracy and follow through, with minimal
- Maintains Protected Health Information with strict confidence
and in a professional manner.
- Ability to use computer software and Microsoft Office
applications, including Excel spreadsheets, is required.
- Understanding of nationally recognized standards of care,
managed care methodologies, and an awareness of dynamics occurring
within the healthcare delivery system are key components of this
- Ability to perform job with integrity and values consistent
with the organization's Mission, Core Values and Standards.
- May be required to work embedded within provider practice as
patient needs and volume dictate.
- Ability to travel to provider practices, hospitals, skilled
nursing facilities, patients' homes, and other sites where patients
receive care as need arises
- Knowledge of defined area of nursing and allied health
services. Familiarity with state-of-the-art developments in medical
- Knowledge of federal and state laws relating to
nursing/clinical care, professional ethics related to the delivery
of nursing/clinical care.
- Knowledge of risk assessment, health status indicators,
multicultural factors, and community health issues.
- Skill in collaborating with colleagues, providers, and patients
to assess health needs of specific populations, developing
strategies and specific programs to address these issues, and
- Must possess excellent interpersonal skills, with a flexible
and creative approach to problem solving. Ability to facilitate
discussion and build consensus.
- Compassionate and able to relate to different clients with
- Strong management, organizational, communication, and
analytical skills required.
- Excellent verbal and written communication, with ability to
practice active listening, conveying clear, concise messages.
Ability to communicate effectively with variety of internal and
- Maintains current evidence-based practice knowledge within
- Demonstrated ability of working effectively as a nurse of an
interdisciplinary team, displaying safe clinical judgment and
- An ability to work independently in remote setting with access
to privacy is essential.
- Familiarity with Accountable Care and the Patient Centered
Medical Home Model a plus
- Bilingual candidates encouraged to apply.PHYSICAL AND MENTAL
REQUIREMENTS:The Physical demands and work environment
characteristics described here are representative of those that
must be met by an employee to successfully perform the essential
functions of the job. Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential
- Ability to work long hours – over eight in a work day, and over
40 in a work week as necessary;
- Regularly required to use hands to finger, handle or feel
objects, tools, or controls; reach with hands and arms; and talk or
- Frequently is required to walk and sit.
- Occasionally required to stand; climb or balance; and stoop,
kneel, crouch or crawl.
- Ability to lift and/or move up to 20 pounds.
- Vision abilities required by this job include close vision,
color vision, peripheral vision, depth perception and ability to
- The dexterity necessary to utilize a computer keyboard on a
regular basis is essential.ADDITIONAL REQUIREMENTS:As a condition
of employment at SoNE HEALTH and for the safety and well-being of
our employees, all employees are required to be fully vaccinated
for influenza and COVID-19. Salary Range: $80,747 - $104,972
Keywords: SoNE HEALTH, Hartford , RN Care Manager, Executive , Hartford, Connecticut
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