Care Management Nurse - Eagle Physicians

Eagle Physicians & Associates is seeking an experienced and detail oriented Care Management Nurse to join our team. This individual is a key member of the primary care team. Coordinates healthcare across the continuum for select patients of Eagle providers. Care coordination may take place both indirectly (via phone or online), in the patient’s home or home setting, and directly (at Eagle sites). Responsibilities include working with patients, families, and their medical care team to provide coordination and continuity of care, including individualized assessment and identification of specific patient needs, promoting patient advocacy, and applying social service intervention across the acute or post-acute care continuum. Will work with individual patients to identify barriers, modify, and/or improve their health care behavior, improve health care resource utilization, and close gaps in care. Will facilitate connecting Eagle providers with the appropriate care management resources of various health insurance companies, community partners, and Triad Health Care Network (THN) or other risk bearing organizations. CM nurses will utilize data to appropriately identify populations at risk, monitor utilization of healthcare resources (ER and hospitalizations etc.), recognize care gaps, improve medication adherence, and achieve above average quality metric scores. Prior Care Management experience required. Minimum of 3 years prior experience in a medical office is strongly preferred. This is a Hybrid position.   Eagle offers competitive pay and a generous benefits package.Our employees love working at Eagle! For 3 consecutive years, staff consistently rank Eagle highly on their annual Employee Engagement Surveys. 92.80% of Eagle employees cite that they see themselves at Eagle a year from now and recommend Eagle as a great place to work!Come join our team and be part of an enriched and satisfied workforce.   Eagle Physicians may pay all support staff employees hired as a .50 FTE or higher on-or-after April 1, 2024, structured bonuses over their first two years of employment with Eagle as outlined provided. Bonus Amounts are  $750.00 at 6 months,  $750.00 at 12 months,  $1,000.00 at 18 months and  $1,000.00 at 24 months.   Paid Maternity/Paternity leave– Eagle provides up to 2 weeks of paid maternity/paternity leave after 1 year employed and 1,250 hours worked for the birth or adoption of a child. Time is pro-rated based on FTE status.    Influenza vaccine required as a condition of employment, please direct questions to Eagle HR. Eagle is an Equal Opportunity Employer.   Schedule: Generally, Monday - Friday 8 AM-5 PM. Schedule subject to change as indicated by manager.   Key Responsibilities:   •    Helps sites and other quality staff develop and implement plans of action to contact patients who need closure in gaps in care, including medication adherence, and coordinates multi-site interventions when appropriate.•    Help sites develop plans of action to promote closer follow-up or appropriate referral of high-cost, high-risk patients.•    Maintain relationships with care management groups of all contracted health insurance plans and ACO (Accountable Care Organization) to connect Eagle providers to the correct care management group.•    Develops relationships with some patients who need care coordination but do not need formal care management follow-up.•    Follow these patients telephonically.•    May see patients as needed at Eagle sites or at home.•    Use care coordination processes to assure quality care is delivered to patients, the patients’ families, and the patients’ caregivers in the most efficient and effective manner across the healthcare continuum. •    Work in the setting of acute or post-acute facilities, offices, and the home setting; augmenting the transitional care work of each facility’s discharge planners in coordination with the centralized PCA Team at Eagle Physicians.•    Apply the principles of comprehensive, community-based, patient-centered, developmentally appropriate, and culturally and linguistically appropriate care coordination.•    Engage patients, patients’ families, and their caregivers in understanding their plan of care and of applicable resources/services in a culturally and linguistically appropriate way.•    Determine patient needs to include consideration of diagnosis, prognosis, and available social support, including utilization of standardized SDoH assessment tools (i.e., PRAPARE).•    Document each patient’s individualized care plan and care coordination goals clearly and concisely in EHR (Electronic Health Record).•    Conduct and document assessments of patient needs and resources for effective self-care management.•    Develop and maintain relationships among patients, patients’ families, and the patients’ care team that support patients’ access to the medical home.•    Participate in continuing professional growth through attendance at workshops and professional in-services and through individual research and reading, to include communication skills.•    Demonstrate personal responsibility and respect for patients, patients’ families, and co-workers in professional appearance.•    Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.•    Apply Motivational interviewing and patient activation concepts when assessing patient’s readiness for change.•    Engage patients in advance care planning discussion when appropriate.•    Adhere to established Eagle policies, procedures and safety regulations which include the wearing of personal protective equipment - report any malfunction in equipment to appropriate individual for investigation and repair.•    Operate medical equipment to include blood pressure cuff, thermometer.•    Make sure restricted or abusable materials to include drugs, needles, syringes, prescription pads and patient medical records are secured and accessible only to authorized medical office personnel.•    Dispose of infectious waste in accordance with training procedures•    Writes legibly and with correct grammar and sentence structure. Demonstrates awareness of patient & visitor fears and apprehensions.•    Participates in professional development activities and maintains professional affiliations.•    Shows respect, courtesy and advocacy in all dealings with all people, including, but not limited to patients, coworkers, and visitors.•    Displays a positive attitude, and team-oriented spirit, indicated by a willingness to assist where and whenever needed.•    Attends meetings as required.•    Follows HIPAA guidelines for patient confidentiality and maintains security of Protected Health Information (PHI) and business information.•    Does not exhibit, divulge, copy or remove the contents of any record or report except to fulfill work assignments.•    Participates in professional organizations as indicated.•    Upholds and exemplifies through daily actions, activities and behaviors Eagle’s Vision, Mission, and Values:o    Vision: Eagle Physicians will be seen as the healthcare organization of choice by patients, staff, and the community.o    Mission: Eagle Physicians will provide patient-centered healthcare for our community with a team committed to high-quality, supportive, and compassionate care.o    Values: Integrity, Compassion, Trust, Professionalism and Respect.•    Upholds and exemplifies through daily actions, activities and behaviors Eagle’s Diversity, Equity, and Inclusion values. •    Performs additional duties as required.   PERFORMANCE REQUIREMENTS: Knowledge, Skills & Abilities •    Self-motivated, dependable, strong work ethic with a desire to learn.•    Strong time and project management skills.•    Ability to work effectively in a team environment and successfully in a fast-paced, stressful environment.•    Experience with computer applications.•    Knowledgeable in the various clinical and non-clinical workflows in a hospital setting, post-acute care facility, and medical practice.•    Familiarity with medical terminology and coding.•    Ability to apply critical thinking skills and make sound judgments both while performing daily responsibilities and throughout the patient’s continuum of care.•    Knowledge and demonstrated abilities to work in a regulatory climate that includes oversight by federal and state rules, payer contracts, governmental benefits, and community resources.•    Effective oral and written communication skills.•    Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate accurately and effectively with all levels of staff and management.•    Ability to interpret and relay to patients (and their caregivers) the applicable Medicare, Medicaid, or private insurance coverage for ordered services to include information about coverage limits and any costs the patient may incur.•    Ability to work with a registry and with electronic health records. •    Empathy, mental alertness, precision, analytical problem-solving abilities, communication skills, focus, and initiative.•    Participate in care team meetings or active panel management as a primary contact point, advocate, and be source of information for patients and the community partners who help treat them.•    Research, find, and link patients to resources, services, and support mechanisms for their identified needs.•    Provide timely communication with patients, make inquiries, execute follow-up actions, and help to integrate information into the care plan.•    Assist the care team by helping to measure quality and identify, refine, and implement performance improvements that support the Practice needs (medical home or facility)•    Continually monitor the cost effectiveness of services provided through the patient’s individualized care plans and recommend any needed changes to those plans based on evidence-based, clinical guidelines from sources identified by the Practice. QUALIFICATIONS •    Prefer three or more years primary care office with experience in case coordination/management.•    Care Management work is desirable.•    Demonstrated skills in leadership, advocacy, communication, education, and counseling.•    Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs. Education: Graduate of an accredited school of nursing. Experience: Minimum three years as RN/LPN with experience in healthcare.  Certificate/License: Active, unrestricted licensure as an RN or LPN in the state of North Carolina and CPR certification. ALTERNATIVE TO MINIMUM QUALIFICATIONS: None