RN Care Manager

The Registered Nurse Care Manager (RN-CM) functions within the full scope of nursing practice, while leading an interdisciplinary team, in the delivery of telephonic, virtual, and in-person care, for nephrology practice patients that participate in value-based care programs. The RN-CC applies the process of assessment, planning, implementation, monitoring, and evaluation to meet the patient’s health care needs across the continuum. The RN-CC serves in full collaboration with providers and health team members to ensure safe, quality, and cost-effective care. This role will require daily travel 4- 5 days a week for the following areas:  Fremont/Pleasanton, CA  Responsibilities include: Manages a panel of patients while applying the nursing process, provider guidance, and applicable care paths to develop a holistic and patient-centric plan of care. Provides care coordination and frequency of contact based on patient complexity, provider input, overall needs, and nursing judgment. Always maintains a purposeful, therapeutic presence. Delegates care to interdisciplinary team members, based on situation, while assuming accountability for measurable, patient outcomes. Guides development of multiple health care partnerships to achieve a positive effect. Holds assistive personnel accountable to complete delegated tasks. Accountable for development and modification of individualized plans of care and their delivery. Uses scientific background, knowledge of motivational interviewing, change theory, and creative strategies to ensure quality, effective, evidence-based and cost-efficient care. Collaborates and ensures high intensity engagement with patients/families, providers and the interdisciplinary team to establish mutual goals based on the patient’s needs or problems. Uses patient’s perspective to support informed decision-making. Evaluates, compares, and interprets ambiguous and changing patient data and overall clinical presentation. Explores patients understanding and knowledge of current health status and provides applicable coaching and education. Understands the patient’s unique perspective and assures right education, right time, right environment for learning. Uses knowledge of complex physiology to monitor, detect, and anticipate early and subtle health status changes. Demonstrates culturally congruent care and evidence-based practice. Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education, and identify overall needs. Prioritizes engagement and patient contact upon care transitions and/or an unplanned ‘crash’ start to dialysis. Coordinates care across the continuum to assure appropriate utilization of clinical and community resources, in conjunction with other members of the care coordination team. Leads and presents patients at Interdisciplinary Rounds. Effectively manages patients through the Transitional Care Management workflow. Act as a patient’s advocate, liaison, and information resource. Escalates all appropriate, critical information to applicable providers and care team members, in a timely manner. Monitors, trends, and documents patient’s response to disease, illness, treatment, and overall plan of care. Provides progress updates to providers and care team, as appropriate. Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications, or increased cost. Supports patients’ care coordination needs both telephonically, virtually, and in-person, based on assessment and nursing judgement. Meets with patients in practice and attends office appointments, as applicable. Develops cohesive and strong team-oriented relationships with providers and office personnel. Performs a majority of the work in-office with patients, providers, and practice staff. Facilitate projects and presentations designed to develop and improve the role of the RN case manager in the value- based care programs. Act as resource and representative for value-based care at health fairs and professional seminars as assigned. Assists with coverage for PTO and open positions as requested. Serves as a preceptor when assigned. Perform other duties and responsibilities as required, assigned, or requested. Qualifications: Degree in Nursing from an accredited institution. BSN preferred. Active, unencumbered clinical level of licensure in the state of practice and/or nursing compact licensure. Active and unsanctioned driver’s license. Basic Life Support (BLS) Provider based certification. Minimum of 7 years of recent experience working in the healthcare industry preferred. Minimum of 5 years of nursing experience working with the chronically ill (CKD/ESRD preferred). Home care, case management, ambulatory nursing, and/or hospital experience preferred. Requires working knowledge of Microsoft Office products. Requires experience with medical records documentation. Knowledge of, and experience with, electronic medical records systems High level of comfort communicating with patients and team members through virtual platforms such as Zoom and Microsoft Teams. Patient-focused. Continuous learner. Outcome oriented. Highly organized with ability to keep accurate schedules, notes, and records. Adaptive and responsive to a changing work environment. Strong interpersonal skills. Excellent written and verbal communication skills. Ability to multi-task and work independently. Thrives in a team dynamic and fosters teamwork and respect. Can develop and adapt procedures and processes with minimal supervision. Commits to the mission, vision, and values of Panoramic Health and to the profession of nursing.