RN Care Manager

Welcome to Cherry Health - video about Cherry Health Overview of Position: The RN Care Manager is responsible for comprehensively developing, implementing, monitoring, and evaluating individualized patient care plans for a targeted patient population. As part of an expanded healthcare role, the Care Manager collaborates with specialists, members of the healthcare team, and patients/families to ensure the delivery of quality, efficient, and cost-effective healthcare services. This position will assist providers in achieving desired patient outcomes by working collaboratively with providers, the multidisciplinary team, and the community medical neighborhood.

The position requires adherence to organizational Policies, Procedures, Code of Ethics, and all licensing and accreditation standards. The RN must also represent the organization’s mission in all actions and communications. This is a full time, benefit eligible position located onsite at our Heart of the City clinic working in our Adult Medicine clinic. Typically working Monday - Friday 8a-5pm. Essential Duties and Responsibilities: Identify targeted high-risk populations within practice sites per primary care provider referral, risk stratification, and patient lists. This includes patients with repeated social and/or health crises.

Assess over time the healthcare, educational, and psychosocial needs of the patient/family using standardized assessment tools such as depression screening, functionality, and health risk assessments. Collaborate with primary care providers, patients, and members of the healthcare team, including continuum of care settings and the community, to develop a comprehensive individualized care plan and targeted interventions. Continually monitor patient/family response to the plan of care and revise the care plan as necessary. Provide patient self-management support, focusing on empowering the patient/family to build capacity for self-care.

Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations. Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines. Act as the lead in ensuring continuity of care that extends beyond the practice boundaries. Serve as a liaison to acute care hospitals, specialists, and post-acute care services. Provide follow-up with patients/families when patients transition from one setting to another.

Complete and maintain required documentation of timely post-hospital visit follow-up, medication reconciliation, primary care provider or specialist follow-up appointments, teaching warning signs, reviewing discharge instructions, coordinating care, and problem-solving barriers. Collaborate with Cherry Health’s leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care models…

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