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Ashland, Virginia, United States
Hybrid
Candidates must reside within NorthLakes' service area at the time of hire and maintain residency throughout employment.
To engage teams and patients in the delivery of evidence-based, patient-centered, lifelong care.Essential Job Functions
Travel Requirement: This RN Care Manager position will travel between our Ashland, Iron River, and Hurley clinic locations on a weekly basis.
The RN Care Manager will manage high risk and chronic illness to promote whole-person, integrated, quality care. The RN Care Manager will employ a person-centered and team approach, partnering with patients and their family/caregiver(s), clinic/hospital/providers and specialty providers and other staff, and community resources.
Conduct in-office patient visits as outlined in care plan and based on patient’s health status and self-management interests
Create and promote engagement with a care plan, developed with the patient, primary care provider and/or specialty care provider and family/caregiver(s)
Support the delivery of integrated, whole-person care in family medicine, recovery and psychiatric care.
Engage patients in self-management and shared decision-making
Increase utilization of preventative care services
Promote timely access to appropriate care to reduce emergency room utilization and hospital readmissions
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
Work with internal providers on coordinating schedules, getting a client in to other service lines as needed
Facilitate patient access to appropriate medical and specialty providers, assisting with residential and detox referrals
Assist with the identification of “high-risk” patients with a chronic illness and those with special health care needs, coordinate care, and track outcomes
Assess for social drivers of health and work with Community Health Workers on integrated Care Management
Attend all Care Management training courses/webinars and meetings – contribute to the development of the Care Management Program
Participate in quality improvement efforts by; utilizing dashboards, tracking tools and providing quality reporting data monthly
Follow protocols, clinical policy and procedure in collaboration with the Primary Care Provider/Specialty Care provider for chronic care management. Follows clinical guidelines protocols and policies related to all direct patient care.
Performs in-clinic triage and medication refills
Work with Triage Nurse team as needed to perform medication refills and triage.
Conducts nursing assessments according to assessment tools to determine services and service level of care needed.
Under provider direction performs and/or assists provider in inductions utilizing COWS, administers patient injections and provides education on naloxone.
Helps monitor OB clients, talking with their OB provider about pain management for delivery and postpartum.
Provides education about Neonatal Abstinence syndrome, support systems, and concerns
General Education with patients about substance use, tobacco cessation, prevention, communicable disease management, new medical diagnosis
Monitor medication adherence, including checking the PDMP, help monitor side effects, provide patient education, assist prior authorizations and prescription assistance programs
Provide medication reconciliation and complete refill requests, including for controlled substances under direction and approval from prescribing provider
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care cost
Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
Facilitate and attend meetings between patient, family/caregiver(s), care team, and community resources, as needed
Qualifications and Education Requirements
Minimum Level of Completed Education: Associates Degree in Nursing
Prior years of experience in similar role: RN with two+ years related experience and/or training
Experience with systems, computer applications/software: Electronic Health Records, preferably Epic.
Required (or Preferred) Licensure/Cert/Credentials: Current, valid and unrestricted WI license to practice as a Registered Nurse. Current CPR certification required.
Evidence of leadership, communication, education and counseling skills. Local knowledge about community health care and social welfare resources preferred.
Benefit Statement
For full time and part time employees who work 24 or more hours per week we offer a generous benefits package that includes:
• Medical and dental insurance
• Employer paid group term life and disability
• Employer contribution toward Health Savings Account
• Flexible Spending Accounts
• Paid Time Off (PTO), Paid Holidays and Paid Leave Bank
• 403(b) with a 4% employer match
Various voluntary benefits:
• Vision Insurance
• Supplemental Life, AD&D and Disability
• Tuition reimbursement
• Health and Wellness reimbursement program
• Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
• Partner of HRSA/NHSC loan repayment program
Our Mission is to respond to the healthcare needs of our communities with an integrated array of quality services and actively remove barriers to wellness.
NorthLakes Community Clinic is an Equal Opportunity Employer. All qualified applicants will be considered for employment regardless of age, race, color, creed, religion, sex, sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.
All offers of employment are contingent upon successful completion of a criminal background check and references.
At NorthLakes Community Clinic, our organizational competencies highlight the behaviors and values that guide how we work and provide a shared foundation for performance, development, and growth throughout an employee’s career with us.
NorthLakes Community Clinic Organizational Competencies
Mission Driven - Advances the organizational mission, vision and values in executing job duties.
Customer Service - Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.
Quality - Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.
Creativity - Generates new ideas, supports change, provides innovative solutions, solves problems creatively.
Integrity - Earns the trust and confidence of coworkers and customers through honest communication, ethical behavior and professionalism in all interactions.
Teamwork - Contributes to meeting team deadlines and responsibilities, listens to others and values opinions, helps team to meet goals, welcomes newcomers and promotes a cooperative team atmosphere.
Self-Development - Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities.
Job Knowledge - Understands duties and responsibilities, possesses necessary job knowledge and technical skills, maintains job knowledge current.
Communication - Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
Dependability - Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
Trauma/Resilience Informed - Understands that trauma is prevalent and resilience can be cultivated and improved; and operates in a manner consistent with these principles.