Clinical Nurse Care Manager - Frederick, United States - Frederick Memorial Hospital

Description

Clinical Nurse Care Manager - Transitional and Chronic Care - Full-time with Benefits

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior.

The Clinical Nurse Care Manager is responsible for the day-to-day coordination of clinical and patient care for patients established care with CCC practice or enrolled in the TCCM program.

This role focuses on improving the health status and care of individuals with chronic conditions, complex medical, mental health, and psychosocial issues, medication management, transitional case management across the health system and patient monitoring.

The Clinical Nurse Care Manager coordinates a wide range of community-based and healthcare support for patients and works with physicians, staff, and other resources in various settings to address patient needs.

• Collaborates with all members of the healthcare team to coordinate the management of patient care across the continuum.
• Functions as a liaison with other Frederick Health departments, community provider practices, and community-based organizations.
• Stays abreast of current evidence-based knowledge and skills for assessing, problem-solving, critical thinking and planning of patient care.
• Maintain current knowledge of community resources and attend continuum education on disease management and care coordination as needed.
• Assesses individual needs and develops plans to address needs/issues relates to condition and overall health.
• Conducts patient/caregiver education regarding condition and symptom management, red flag warning signs, medication reconciliation and barriers to care telephonically, in the office, or in the patient's home.
• Establishes self-management goals with patient using self-management support concepts and motivational interviewing techniques.
• Administer IM or Sub-Q injections.
• Assist with diabetes education, continuous glucose monitoring equipment, and filling of insulin syringes if needed.
• Provides clear and thorough documentation within 24 hours of patient encounter.

• Knowledge of disease management in acute and post-acute settings
• Ability to effectively communicate both verbally and in writing with a broad range of individuals, proficient in e-mail communication and internet usage along with basic use of Microsoft Excel and Word that includes ability to enter data, retrieve it and generate reports.
• Ability to prioritize assignments, strong organizational and time management skills.
• Must be detail oriented, flexible, and committed to patient advocacy and with basic knowledge of psychosocial aspects of patient care.
• Excellent critical thinking and problem-solving skills with an ability to function independently and multitask in a fast-paced team environment.
• Valid Drives License and reliable transportation

• BSN preferred.
• Graduation from an accredited school of Nursing with a current license from the State of Maryland
• Three years of experience in acute care setting, physician practice, home health care or other community setting
• Familiarity with local social determinants of health
• Experience working with high-risk minority populations.