SUMMARY:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required for this position. Reasonable accommodations may be made, upon request, to enable individuals with disabilities, who otherwise meet the qualifications, to perform the essential functions of the position.

JOB SUMMARY

The Nurse Care Manager will work on an interdisciplinary healthcare team in a specialty care setting to conduct direct patient care and quality improvement activities. He/she will be part of a program charged with implementing strategies to meet specified quality measures. The Nurse Care Manager is responsible for providing comprehensive screenings, assessments, care coordination services, disease education, and self-management support to patients with chronic kidney disease. The Nurse Care Manager will be integrated into the office-based healthcare team to promote patient-centered care, frequent contact with primary care providers, and dialysis centers. The Nurse Care Manager will have a key role in educating patients about renal replacement therapy, kidney transplant, palliative care, hospice, and preparing the patients for their chosen modality. The Nurse Care Manager will also be part of a team responsible for preventing hospitalizations in the dialysis population and patients identified as at risk for rapid progression to a requirement for dialysis. Patient care activities will be conducted in person as well as via telehealth.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Consistently applies the Brown Medicine values of patient care priority, dignity, collaboration, integrity, inclusion, respect for diversity, and quality in support of the mission to deliver compassionate, high-quality patient care, research excellence and outstanding physician education within a culturally sensitive environment. Is responsible for knowing and acting in accordance with the Compliance Program and Code of Conduct.

Consistently practices the Brown Medicine Customer Service Standards.

• Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
• Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care.
• Establish and document care plans, interventions, treatment goals; utilize motivational interviewing techniques to assist patients with establishing self-management goals on all patients with ckd/esrd.
  • Promote compliance with chronic care plan.
  • Coordinate care and communicate with multiple providers, both within and external to the practice, with particular attention to transitions of care.
  • Review test results and tracks outcomes.
  • Review medications and work with providers and clinical pharmacist as needed to assist with medication management
  • Assess patient compliance and risk issues. Work with patient/family/care team to reduce risk.
  • Work one-on-one with patients.
• Identify and utilize cultural and community resources to resolve barriers to care.
• Follow established Brown Medicine EMR workflow protocols to maximize site’s productivity and office flow efficiency.
• Ensure open communication, regarding patient status, with physicians and office staff with clear and concise documentation in the EMR
• Provide training to medical staff as needed.
• Act as liaison to dialysis units, hospital, long-term care, specialists, and home health representatives.
• Follow-up with all dialysis patients seen for an ER visit and/or hospitalization for continuity of care and to market enhanced access and reduce utilization.
• Attend required training and collaboration sessions 
• Perform quality work within deadlines within the Division of Chronic Kidney Disease and Hypertension.
• Represent the practice in a positive manner to all patients and all applicable external clients.
• Bring issues to the appropriate manager(s) in a timely manner for resolution.
• Perform other related duties as assigned.
• Attend and be prepared for all internal meetings.
• Meet all required contractual obligations and visit/intervention requirements.

BASIC KNOWLEDGE:

• Ability to work independently and collaboratively to achieve goals.
• Highly organized and detailed.
• Exercise sound judgment and decision-making. Able to assess and differentiate priorities.
• Excellent interpersonal skills and ability to work with and through people to get the job done. 
• Excellent written and verbal communication skills.
• Able to maintain confidentiality with all aspects of information (including patient data) in accordance with the practice’s philosophy and policy, and state and federal regulations. Must handle the most sensitive and confidential matters with the utmost discretion.
• Proficiency with computer skills (i.e., Microsoft Word, Excel and Access, and Web-based applications).

EXPERIENCE:

• Degree in Nursing from an accredited school. 
• Three (3) to five (5) years experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
• Experience working with primary care providers to coordinate care and disease management.
• Receipt of certified diabetes outpatient education (CDOE/CVDOE) or willingness to obtain this certification within 2 years of hiring.   
• Experience working with CKD/ dialysis patients regarding their care coordination and disease management / education is preferred.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:

Conditions common to a clinical practice environment including potential exposure to communicable diseases, medicinal preparations and hazardous materials.  Involves frequent contact with patients.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Travel to office sites and dialysis units as needed.

LICENSES:

• Licensed RN, State of Rhode Island