RN Care Manager - Westwood
1 month ago
Position Purpose: Coordinates and manages care for the high and rising risk population through multiple care delivery systems, supporting patient in self-management of their health.
Coordinate and manage care of high-risk population Complete telephonic outreach and home visits as applicable based on patient acuity. Performs a comprehensive care management assessment of patient needs to ensure optimal health outcomes. Develops a self-management action plan of care, coordinates services and navigates the patient through the health care system with a goal of enabling the patient and family to effectively manage their condition(s) and optimize outcomes.
+ Collaborates with patients'care team including but not limited to hospital team, primary care team, specialists, home care SHCN clinical programs, any others involved with patients'care approved by the patients to ensure effective coordination of services full understanding execution of the-care plan Maintains required medical documentation for -care management activities electronic medical records according standards work Follows standards work consistently maintains department established caseloads timeframes case completion Documents reports quality-patient safety events recording adhering all Revere Medical's safety reporting guidelines Performs other duties assigned Process Improvement Evaluates processes identifies problems proposes improvement strategies enhance delivery -of-care forpatients throughout continuum-of-are Escalates barriers positive-outcomes supervisor manager same day Participate refinement development new standards work Maintains awareness key performance indicators/metrics managements caseload interventions prevent adverse-events ED visits hospital admissions readmissions Attend staff meetings education offerings both person via teleconference as required
Job description
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