Coordinated Care Manager

Summary:
Ensures consistent high-quality nurse care management of complex patients in an effort to reduce unnecessary utilization.
Responsibilities:
Identification and assessment of the rising-risk and high-risk patient population
Identifies the targeted rising-risk and high-risk population within practice site(s) per Primary Care Provider (PCP) referral risk stratification and according to an established high-risk definition
Identifies hospital-based patients and overviews care management and safe discharge planning including identification of barriers on morning conference call with interdisciplinary care teams
Development implementation and updating of care plans
Manages a panel of high-risk patients to establish care management plans interventions treatment goals and self-management goals
Develops care plans for patients upon admission into high-risk care management program and updates quarterly
Encourages and supports high-risk patients to maintain adherence to their care plans
Coordination of patient care
Assesses the healthcare educational spiritual social and psychosocial needs of the patient/family
Determines individual patient needs for services referrals and training and provides patient education pertaining to health status medications discharge planning safety and other needs
Assisting patients with self-management through in person education and telephonic engagement
Conducts ongoing assessments both in person and telephonically coordinating care conferences with providers and collaborating with the healthcare team
Assists patients in navigating the healthcare system
Engages high-risk patients to actively manage their health
Assesses readiness for complex care conversations with patients and families
Collaboration with the practice and specialty care teams
Collaborates patient care with PCP and all members of the healthcare team including any required health care services outside of Brown Health Medical Group Primary Care
Ensures open communication regarding patient status with physicians office staff BHMGPC centralized clinical services and patients' families
Identifies and utilizes cultural and community resources
Acts as liaison to hospital long-term care specialists and home health representatives
Attends required trainings and practice team meetings as scheduled
Mentors Care Navigator and actively supports role development and scope of practice
Complies with federal and local confidentiality laws including HIPAA ensuring patient privacy
Adheres to Brown Health Medical Group Primary Care guidelines for protecting patients* demographic clinical and financial information
Performs other miscellaneous job-related duties as assigned
Other information:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing

or

licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.
Location: Brown Health Medical Group Primary Care USA:RI:Providence
Work Type: Full Time
Shift: Shift 1
Union: Non-Union
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