Reliant Medical Group is seeking a Chronic Nurse Case Manager to join our exciting and innovative team!
Department: Care Management
Position: Full-time 40 hours per week
Hours: Monday - Friday 8:00AM - 4:30PM
No weekends or holidays
Manages all aspects of patient centered care for a panel of patients with identified needs, while working as part of a health care team (Providers, Nurses, Social Workers, Patients, Family,Caregivers, etc)
* Provides comprehensive case management and care coordination for a panel of patients with identified needs. \"Coaches\" (rather than \"teaches\") patients to improve their health behavior to attain health-related goals. * Completes a comprehensive patient needs assessment for each patient. * Develops and communicates (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice for chronic illness. * Proactively manages and follows-up (using home visits and telephone calls) according to careplan. * Manages and coordinates all transitions of patient's care. * Communicates care plan to all providers in all settings of care (emergency department (ED), hospital, rehabilitation facility, nursing home, home care and specialist). * 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 care). * Directs caregiver support, including ad hoc telephone advice. * Facilitates patient and caregiver access to community resources relevant to patient needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services,etc. * Incorporates self-care and shared decision making in all aspects of patient care. * Complies with health and safety requirements and with regulatory agencies such as DPH, etc. * Complies with established departmental policies, procedures, and objectives. * Enhances professional growth and development through educational programs, seminars, etc. * Attends a variety of meetings, conferences, and seminars as required or directed. * Performs other similar and related duties as required or directed. * Regular, reliable and predicable attendance is required.
* Graduate from an accredited school of nursing. * Active, unrestricted licensure as a RegisteredNurse in Massachusetts; current Massachusetts driver's license. * Certified in Geriatric Nursing or Geriatric Case Management preferred. * A minimum of five years nursing experience, preferable with older patients. * Excellent communication, interpersonal and organizational skills, with a flexible and creative approach to problem solving. * Works effectively both independently as well as a member of an interdisciplinary team. * Proficient in computer use, the Internet and health information technology. * Ability to travel to hospitals, skilled nursing facilities, patient's homes,and other sites where patients receive care as needed.
Associated topics: asn, bsn, cardiothoracic, care, coronary, infusion, maternal, nurse clinical, psychiatric, unit