Registered Nurse Care Manager - Community Liaison

DESCRIPTION:

The RN Care Manager – Community Liaison is a critical member of the care team consisting of nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position will be working closely with complex renal patients in their home and from within nephrology practices, dialysis centers, by phone and electronically as needed. The primary focus will be to improve patient outcomes by helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating their care.

RESPONSIBILITIES:

• Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; The Registered Nurse Care Coordination Case Manager is expected to conduct approximately 12 assessments per week

• Based on this assessment, and in conjunction with the patient, patient's nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient;

• Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s);

• Facilitate care across the continuum of care, spanning settings such as the home, their physician's office, hospital, skilled nursing facility, and acute care facility;

• Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions;

• Assess the patient's knowledge of their renal condition and provide education and self-management support;

• Provide ongoing reassessment and follow-up to improve patient outcomes.

• Provide clinical oversight to non-licensed support team of community health workers and health coaches and licensed support team of social workers and renal dietitians, and delegate tasks as appropriate.

• Promote open communication with health care partners

MEASURES OF SUCCESS:

• Provider Relationships.

• Dialysis Interventions monitoring and coordination.

• Medical Management.

QUALIFICATIONS:

Required

• 3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings.

• Current, unrestricted compact Registered Nurse license.

• Core values consistent with a patient-centered approach to care.

• Proactively acts as a patient advocate and responds with resolve.

• Knowledge and experience to empower patients in self-management and shared decision making.

• Enjoys working collaboratively with team members and physicians.

• Proficient at multi-tasking and prioritization, working in a high-volume environment.

• Able to evaluate necessary quality metrics for preventative measures and disease management.

• Highly developed interpersonal skills including motivational interviewing skills

• Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.

• Strong analytical and critical thinking skills.

• Strong community engagement and facilitation skills. Able to facilitate communication of patient status and plan of care during transitional experiences.

• Ability to travel throughout the assigned region and comfort with conducting home visits (up to 75% same day travel).

Preferred

• Bachelor's Degree in Nursing.

• Demonstrates empathy, enthusiasm, a great sense of humor, and a strong work ethic.

• Experience working with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.).

• Ability to establish rapport with patients, families, and physician offices by inquiring and listening.

• Familiar with electronic medical records.

• Experience working in a physician office

• Flexibility in work schedule to accommodate the needs of patients and caregivers

• Community Outreach experience, preferred.

• Competence using MS Office products and telecom devices.

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.