About Job

SUMMARY

The RN Care Manager must be committed to Foremost Family Health Center’s Mission, Vision and Values of caring for and providing high quality comprehensive services to the community while driving a culture of engagement and collaboration. The Care Manager is responsible for direction of patient care in the ambulatory care setting. Manages site nursing staff (LVN Care Coordinator, LVNs, and MAs.) Consults with staff, physicians and Director of Nursing on nursing problems and interpretation of Foremost Family Health Center (FFHC) policies to ensure patient needs are met. Maintains performance improvement activities within the department and participates in CQI activities. Oversees care team and the coordination of patient care at the appointed site. Responsibilities include the management of high risk populations as determined by the Chief Medical Officer. The care manager is responsible for the identification of hospital admissions, hospital re-admissions, Emergency Room visits and ensuring proper follow-up of the FFHC patient.

FLSA STATUS: Exempt

SUPERVISOR: Chief of Nursing

DIRECT REPORTS: LVN-Care Coordinator, LVNs, Medical Assistant’s (MLK)

DUTIES AND AREAS OF RESPONSIBILITY

Follows PCMH Model of patient care, coordination and all related PCMH elements.
Implements Care Coordination Team functions.
Communicates with local hospitals, clinics, specialists and insurance plans to ensure proper follow-up after a hospital admission, Emergency Room and specialty visits.
Serves as a super-user on electronic health record and other related clinical software as assigned.
Collaborate with MD/PA/NP on the assessment of patient primary and chronic diseases.
Utilizes appropriate disease management techniques.
Educates the patient and family regarding disease process.
Implement proper calculations on immunizations / medications dosing and administration, based on age of the patient and their clinical condition.
Formulates a teaching plan, based on identified patient learning needs, and evaluates effectiveness of learning. Family is included in teaching, as appropriate.
Communicates routinely to assure compliance with visits and medications as appropriate to disease, minimizing medication errors.
Performs waived testing (point-of-care testing), and provides results to MD/PA/NP, and takes appropriate action as required.
Assists providers and team members with procedures.
Organizes and manages nursing activities at assigned site.
Maintains flexibility in implementation of procedures.
Leads team members and coordinates member activities to assure continuity and monitoring of patient care on PCMH model.
Treats patients and their families with respect and dignity; identifies and addresses psychosocial needs of patients and family.
Provides direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care.
Maintains accurate and continued nursing documentation including patient histories, conditions, treatments, responses and assessment of changes.
Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patients served.
Able to interpret data about the patient’s status in order to identify each patient’s age specific needs and provide care needed by the patient group.
Manages and performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
Communicates appropriately and clearly to the Director of Nursing, physicians, customer service, and other administrative team members at all sites.
Provides education to staff on performance improvement documentation.
Plans and organizes orientation and in-service training for facility staff members; participates in guidance and educational programs.
Maintains a good working relationship and effective communication both within the department and with other departments.
Develops, revises, and implements policies and procedures that are identified vital to patient care and care management.
Performs care management, and when necessary, assigns personnel, delegates specific duties and tasks, and assures completion of assigned tasks.
Holds staff accountable for task completion, verbally and in writing.
Conducts annual staff performance appraisals in conjunction with clinician input.
Demonstrates an ability to be flexible, organized and function under stressful situations.
Continuously supervises staff to ensure quality of nursing care, and leads/participates in site huddle per protocol. Provides recommendations and/or completes evaluations as indicated and submits timely to the Director of Nursing for review.
Other duties as assigned.

EDUCATION AND/OR EXPERIENCE

Graduate of an accredited school of nursing, college or university with care management/ambulatory care experience. Bachelor of Science in Nursing preferred.
Must hold a current and active Texas RN license with no restrictions.
Minimum three (3) years of experience as a RN in a clinical practice field in a hospital, community health center, or an ambulatory care position.
Must be qualified in BLS techniques.
Must have a working knowledge of OSHA Bloodborne Pathogen Standards and Risk Management.
Must have a working knowledge of Microsoft Office products and familiarity with network systems.

LANGUAGE SKILLS

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write correspondence and routine reports.
Ability to communicate and interact effectively in person and via telephone with employees, patients, and family members from various educational and socio-economic backgrounds, the public, and the Leadership Team.
Must be able to make clear and concise oral and written presentations.

Job Type: Full-time

Pay: $38.00 - $40.00 per hour

Benefits: