Nurse Care Manager - Bear River Family Medicine
Location: Tremonton, Utah
Description: Intermountain Home Care is employing Nurse Care Manager - Bear River Family Medicine right now, this job will be reside in Utah. Further informations about this job opportunity kindly read the description below. :
To work collaboratively with physicians and other members of the health care team to improve the health of patients with chronic conditions and/or compl! ex needs. To educate patients and families to help them manage their health care needs. To facilitate communication, coordinate services, address barriers, and promote optimal allocation of resources while balancing clinical quality and cost management.
Entry Rate: $26.38
Benefits Eligible: Yes
Shift Details: This is a full-time, benefits-eligible position. Must be available to work 36 hours per week. Shifts will be Monday through Friday.
Job duties may include, but are not limited to the following:
Patient Populations
General case management
Respond to physician referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or B/P, Mental Health Integration referral, complex resource needs)
Patient Evaluation
Assess family, social, cultural characteristics
Understand communication needs (vision/hearing)
A! ssess behavioral and family risk factors
Assess barri! ers
Screen for chronic disease (e.g. depression)
Review patient understanding of medication treatment
Chronic Disease Management
Have working knowledge of established care process models and other applicable standards of care
Provide focused patient education using established content and tools
Use clinician approved and appropriately documented standing orders
Establish individualized care plan including treatment goals in collaboration with patient and consistent with medical plan of care.
Review care plan and assesses progress toward treatment goals and barrier at each relevant visit
Coordination of Care
Coordinate with care managers in other settings as appropriate
Provide information on enabling services (e.g. transportation)
Maintain list of key community services agencies with contact information
Provide information about recommended or available servi! ces and contacts
Personalized Primary Care
Support Patient in Self-Management and Behavior Change Using Motivational Interviewing and Coaching
Assess readiness to change
Assess and track patient capacity for and confidence in self-care
Develop self-care plan in collaboration with patient
Provide self-monitoring tools
Provide or connect patients with support programs
Assess and support patients in adopting healthy behaviors
Assess and arrange treatment for mental health and substance abuse problems
Manage Populations, Disease Registries and Preventive Care
Establish process to monitor patient adherence to medical plan of care.
Focus on prevention measures consistent with established guidelines and care process models
Review and manage quality reports related to chronic disease and prevention
Support clinicians in achieving quality incentives
! Team Based Care
Work collaboratively with referring physician ! and other members of care team
Personalized Primary Care
Complete pre-visit planning (review chart before visit, notify patient of tests needed before the visit)
Facilitate advanced care planning (Advanced Directives)Establish process for reminder letters and phone calls
Support clinicians and team to achieve personalized primary care goals
Facilitate transitions of care (unscheduled hospital admissions, emergency department visits, skilled nursing home)
Track status of critical referrals
Follow up to obtain report back from referral clinician
In collaboration with clinician, establish written care plan for patients transitioning from pediatrics to adult
Provide information on health insurance resources
Supervise and support Health Advocates
Attend clinic team meetings and medical home meetings to assist with process design and help resolve team issues
Support develop! ment of agenda for team meetings
Review data summary on regular basis
Minimum Qualifications:
Three years of Registered Nurse experience
Current Utah State Registered nurse license
Basic Life Support (BLS)
Bachelor's Degree in Nursing (Education must be obtained through an accredited institution. Education is verified)
Must function with a high degree of autonomy, communication and interpersonal skills.
Must understand the health care continuum and have the ability to solve complex problems
Basic computer skills and knowledge of word processing software
Preferred Qualifications:
Ambulatory and/or care management experience preferred.
Experience working as a Nurse Educator
Physical Requirements:
Seeing, Hearing, Speaking, Listening, Manual Dexterity
Salary: . Date posted:
- .
If you were eligible to this job, pl! ease email us your resume, with salary requirements and a resume to Int! ermountain Home Care.
Interested on this job, just click on the Apply button, you will be redirected to the official website
This job will be started on: Sun, 03 Nov 2013 03:53:39 GMT
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