Advanced Primary Care, RN Care Manager Primary Care Mentor

A Brief Overview

UH Lake House Calls Program. Mon-Friday, no weekends, no holidays, no call, no rotating shifts. Work directly with House Calls APP's in the home setting. Provide support to office staff and triage of high volume calls. Provides comprehensive case management for homebound patients with complex, chronic medical conditions. Collaborates with primary nurse practitioners to ensure continuity of care, reduce hospitalizations, and improve quality of life. Advocates for patient access to appropriate resources and services. Travel to patient homes with mileage reimbursement.

50% travel covering Lake, Geauga and Ashtabula Counties

What You Will Do

• Exercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands. The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities.
• Provide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient's condition/situation and take appropriate action. Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc.
• Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.
• Work as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes
• RN care management integrated into Primary Care office responsible for managing patient's care across the continuum
• Analyze sources of data to identify high risk patients and member groups
• Manage high risk patients including patients with multiple comorbidities or high risk for readmission
• Develop longitudinal care planning that includes assessment, planning, implementation and monitoring
• Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits
• Advocate for patients by assisting in navigation of the health system
• Communicate to the care team the patient's goals and progress
• Participate in quality improvement initiatives
• Participate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement
• Provide 1 on 1 office visits for patients to implement care planning
• Provide health and disease education to patients and families, including group education opportunities
• Support patients in self-management of their disease and behavior modification interventions
• As a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach
• Collaborate with office staff in the coordination of individual patient care needs
• Support and facilitate advanced care planning for patients and their families
• Demonstrate proficiency and act as an expert role model in the performance of patient care

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.