Social Worker Care Manager
Ennoble Care
Registered Nurse (RN), Ambulatory Care Manager, Population Health
Bon Secours Mercy Health
full-time
Posted on:
Origin: • 🇺🇸 United States • South Carolina
Visit company websiteJob Level
JuniorMid-Level
About the role
- Provide clinical care management services to identified eligible patients; coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care.
- Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources.
- Collaborate with patient, provider and care team to develop and implement a plan of care to ensure medically appropriate cost-effective care.
- Utilize Motivational Interviewing techniques to activate patients in self-management of their chronic conditions.
- Maintain a caseload of patients according to department policies; identify, enroll and manage patients in program for Transitions of Care/Complex Case Management/Chronic Disease Management.
- Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols.
- Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen.
- Collaborate with PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
- Perform patient outreach according to established protocols and document in electronic medical record.
- Identify, execute, and track needed referrals to care and community resources.
- Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
- Assist patient in advanced care planning to complete Advanced Directives.
- Document all communications with patient and/or care team in electronic medical record.
Requirements
- Minimum Education: Associate’s Degree in Nursing
- Preferred Education: Bachelor’s Degree in Nursing (BSN)
- Licensure/Certification Required: Registered Nurse with active License in State of Patient Care
- Licensure/Certification Preferred: Case Management certification
- Minimum Years and Type of Experience: 2-3 years acute care, home health or case management experience
- Other Knowledge, Skills and Abilities Required: Excellent interpersonal communication and negotiation skills
- Other Knowledge, Skills and Abilities Required: Strong analytical, data management and computer skills
