Job Description

Job Title: RN Care Manager

Job Code: RNCM

Department: Primary Care/Diabetes/Snowbird/Peds/CCC

Division: Nursing

Salary Level: Non-Exempt 12

Reports to: RN Lead/Primary Care DON

Last Revised: March 2022

Primary Function

The incumbent performs nursing procedures to patients of all ages independently within the framework of established policy. The Registered Nurse is a licensed professional nurse responsible for assessment of patients, development, implementation and evaluation of a patient plan of care; administration of therapeutic measures; teaching and counseling of patients and families; and participating in the development of nursing policies and procedures and quality assurance standards. The Registered Nurse is responsible for the delivery of comprehensive health care to patients of all ages, utilizing standards of care and practice, policies, protocols, and procedures. The purpose of the work is to perform the full range of the nursing process from assessment to evaluation. The work affects the physical and psychosocial well being of the patients and their families.

Job Description

• Utilizes best practice models to identify, incorporate or develop best practices for panel management.
• Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages panel by addressing and resolving acute care needs and chronic care needs through a team based approach.
• Incumbent will be responsible for leading their pod and assisting the Primary Care Provider in panel management that results in meeting facility, national, and regulatory quality indicators.
• Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators.
• Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations.
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care.
• Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatment notes are available to the PCP timely.
• Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH and AMH+).
• Provides standard nursing care for patients throughout the age continuum.
• Develops implements and evaluates care plans.
• Promotes health care outcomes with currently accepted clinical practice guidelines.
• Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources.
• Assesses patient needs using established clinical guidelines, protocols, and pathways.
• Provides appropriate follow up as directed or per established guidelines.
• Provides nursing care in accordance with established nursing care standards, participates in routine and specialty clinics, curative, rehabilitative, and preventive nursing care. On rare occasions may be required to participate in emergency care.

Educational Requirements

• Bachelor or Associate Degree in nursing from an accredited program required.
• Minimum of two years of nursing experience preferred.
• Applicant must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.
• Applicant must have a valid North Carolina driver’s license.

Job Knowledge

Knowledge of principles, practices, techniques, and theories of professional nursing in order to plan and provide nursing care to meet the physical, emotional, spiritual, and socio-cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2 years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years), Adolescence (16-20 years), Adult (21-64 years), and Elderly (65+ years). Knowledge of the nursing process and its application to clinical practice. Knowledge of the biological aspects of the disease process and illness in order to recognize complications and therapeutic interventions required. Knowledge of medications and dosages in order to recognize desired effects, side effects, and complications of their use. Knowledge and ability to analyze the results of various medical procedures and translate into appropriate nursing interventions. Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations. Knowledge of the occupational functions of multi-disciplinary health care team. Knowledge of the culture and medical health profile of the patient population. Knowledge and ability to teach and counsel patient/family on health maintenance and disease prevention. Knowledge of available health care programs and community resources. Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for the practice of nursing. Knowledge and skills in operating specialized medical equipment, such as, monitoring devises, suction pumps, oxygen equipment, etc. Knowledge of problem oriented medical record methods. Knowledge of legal and ethical aspects of nursing.

Complexity of Duties

The incumbent will be responsible for leading a team (pod) and will be expected to function in a leadership role. The RN role requires flexibility and the ability to lead team members who possess a variety of personalities. The RN role necessitates the incumbent to always maintain a high level of integrity, poise, and control.

Responsibility for Accuracy

The incumbent has a positive effect upon the recovery of the patient and is responsible for following policies and procedures, which serve as hospital guidelines and prevents errors from occurring. Errors can have a negative patient outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent.

Contacts with Others

Contacts are with patients, families, hospital personnel, and community agencies. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required

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