Executive Director
Aledade, Inc.
RN Care Manager
HarmonyCares
full-time
Posted on:
Origin: • 🇺🇸 United States • Florida
Visit company websiteJob Level
JuniorMid-Level
About the role
- Manage a caseload of high-risk patients including Transitional Care Management and Chronic Care Management
- Provide Disease Management Education, Medication Education, and develop and manage patient care plans
- Serve as co-chair of the pod with the pod leader to drive and prioritize patient needs to improve outcomes
- Coordinate care services with the pod leader and care team to ensure comprehensive services throughout the healthcare journey
- Coordinate transitions of care across the continuum to prevent avoidable hospital admissions
- Coordinate and facilitate High Risk Huddles and ensure follow-up actions are completed
- Prioritize patients based on severity and urgency and review medical records to identify gaps in care
- Perform thorough nursing assessments via telephone and regularly update patient care plans
- Provide education to patients and caregivers on disease, medication, health maintenance, and disease prevention
- Document interactions, assessments, and updates in patients' medical records according to processes and guidelines
- Serve as liaison between patients, providers, and resources and facilitate communication during transitional experiences
Requirements
- Active Registered Nurse License
- 2+ years of care management experience in community, health plan or hospital systems
- Possesses strong clinical skills and proactive thinking
- Effective communication skills
- Ability to perform extensive telephone assessment
- Knowledge of Medicare regulations and home care and hospice standards
- Experience with small group presentations and teaching/training
- Exhibits excellent interpersonal skills
- Exhibits excellent written and oral skills
- Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
- Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner
- Preferred: Bachelor of Science in nursing or related field
- Preferred: May be required to obtain multi-state licensing
- Preferred: Strong knowledge of population health, quality measures, care gap closure and value-based care models
- Preferred: Bilingual -Spanish/English
