- Collaborate with a care team to identify and proactively address the care needs of high-risk patients in a primary care setting
- Offer assessment, care coordination, advocacy, and coaching for at-risk patients to reduce hospital admissions or emergency room visits
- Utilize specified Finger Lakes Health System Agency (FLHSA) CMMI grant criteria to pinpoint at-risk patients
- Determine risk factors in partnership with patients, families, physicians, and other healthcare providers
- Evaluate the effectiveness of care coordination efforts and regularly reassess patients' risk for adverse health outcomes
- Ability to establish and enhance a practice-based care management model through on-site and telephonic services such as wellness initiatives, health coaching, self-management strategies, disease management, and case management in alignment with FLHSA standards
- Identify high-risk patients requiring care management services
- Deliver education, support, and outreach to patients both over the phone and in person, ensuring compliance with all FLHSA program requirements for family practices
- Work closely with clinical teams to address care gaps and enhance clinical outcomes for patients with chronic illnesses like diabetes
- Active participation in Thompson Practices' quality programs, including PCMH and Diabetes Recognition Program
- Stay updated on clinical practice guidelines and advancements in chronic disease management by regularly reviewing medical literature and sharing relevant information with staff
- Adhere to all necessary Joint Commission, state, and federal regulations
- Must hold a current New York State Registered Nurse license
- Valid BLS certification
- Proficiency in Electronic Medical Records (EMR) usage
- Capability to generate reports independently and collaborate with EMR vendors to create new reports
- Proficient in Microsoft Office applications (Word, Excel, Outlook, PowerPoint)
- Excellent oral and written communication abilities
- Knowledge and experience with Patient-Centered Medical Home and Diabetes Recognition Program is advantageous
- Preferred background: 3-5 years of clinical nursing or social work experience, particularly in community health with adults
- Prior experience with Electronic Medical Records
- Experience in database entry and reporting is a plus
- Prior experience in Care Management is beneficial
- Active NY state nursing license
- Graduate from an approved nursing school
- BSN degree is mandatory
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RN Care Manager - Canandaigua, United States - Thompson Health
Description
Looking for an opportunity to utilize your nursing expertise in an administrative role with full-time hours, Monday to Friday, during the day, in a healthcare system that prioritizes both patients and healthcare professionals like you? Thompson Health is the ideal place for you.
Main Responsibilities:
Required Skills for the Role:
Required Qualifications: (Licenses, Certifications)
Experience:
Education:
Salary Range for the Position: $70,000-88,000 annually
Initial Compensation: Based on individual experience
Thompson Health is an Equal Opportunity Employer that encourages applications from women, minorities, individuals with disabilities, and veterans
