RN Care Manager - AZ Based
Revere Medical
- Paradise Valley, Arizona, United States
- Paradise Valley, Arizona, United States
Über
Engage patients and their support systems, assessing health and risk status and establishing patient centered care plans Provide early intervention related to condition/lifestyle management, medication adherence and address any unmet social determinants of health (SDOH) needs Promote advance care planning and navigate patients through process to outline their healthcare wishes Coordinate with inpatient and outpatient multi-disciplinary care teams to ensure a safe transition of care, including scheduling of timely PCP post-discharge follow up appointments and referrals to social work Serve as a patient advocate and point of contact to ensure continuity of care Monitor patients as they transition from facilities to home, completing post-discharge follow ups for 30 days, medication reconciliation, reducing patients' overall risk of readmission Actively engage and collaborate with PCP's and office staff in identifying high-risk patients Maintain a core understanding of population health, value-based care and the clinical management of at-risk patients Employ motivational interviewing skills to elicit optimal patient engagement/outcomes Perform comprehensive assessments identifying risk factors and addressing barriers to care such as medication adherence, SDOH factors and health literacy Able to develop self-management action plans with patients Partner with Clinical Pharmacist, Social Work, Care Coordinators and payer partners to develop focused interventional programs for patients with chronic conditions or complex social or behavioral needs Identify and address gaps in care across empaneled population Leveraging a deep understanding of chronic disease pathophysiology and coincident symptoms/comorbidities, coach patients & caregivers on health conditions, self-management techniques and develop escalation plans in the event of a decompensation Complete timely documentation of clinical interventions in applicable care management and EMR systems Develop and maintain effective professional working relationships with assigned PCP practice(s) and multidisciplinary clinic staff Facilitate positive patient interactions designed to support all care management functions Serve as a preceptor for onboarding care management team members
Skills For Success
Strong Motivational Interviewing and rapport building skills A passion for changing the way healthcare is delivered and experienced for complex and/or disadvantaged patients and communities Ability to quickly build trusting relationships by following through on commitments Agile, solution focused, problem-solving experience Thrive in a fast-paced start-up environment and able to manage competing priorities A desire for continuous learning that is aligned to updated clinical protocols and best practice recommendations Strong time management and organizational skills with a demonstrated history of timely documentation and collaboration The ability to adapt quickly to changing demands in the healthcare industry A service orientation and a "can do" attitude Displays Strength-Based Approach to collaborative problem solving The ability to receive feedback and apply it to work performance Demonstrates consistently, strong ethics and sound judgement Ability to engage diverse populations (age, ethnic groups, socio-economic levels, etc.) and provide culturally sensitive coaching, education and assistance to members and their families/caregivers Experience in conflict management and problem resolution A low ego and humility; an ability to gain trust through good communication and doing what you say you will do
Experience To Drive Change
3+ years of direct, clinical nursing experience Registered Nurse with an unincumbered license in the state of practice Care management experience in a primary care or inpatient setting preferred Valid driver's license and personal transportation for community visits Comfort and efficiency with technology including Microsoft suite of products Utilizing a variety of electronic health records including data capture, data mining and reporting
Why You Will Love Working Here We take care of our team so they can take care of patients. Benefits include:
Medical, dental, and vision coverage Company funded HSA + exclusive healthcare discounts 401(k) with company match Company paid life insurance Flexible time off + Vacation Exchange Program Medical Assistant Certification Reimbursement
What We Value Trust. Ownership (Together). Compassion. Relentless Progress. These values shape how we show up for patients — and for each other. If you're ready to grow, make an impact, and be part of a connected care team, we'd love to connect. Bookmark Medical is committed to a workplace that supports and sustains inclusion and belonging. Bookmark Medical does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, national origin, age, physical or mental disability, pregnancy, childbirth or related medical conditions, military service obligations, citizenship, sexual orientation, genetic information, or any other characteristic protected by applicable local, state, or federal law.
Sprachkenntnisse
- English
Hinweis für Nutzer
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