Complex Care Manager RN, Pop Health, 40 Hours (Days)
Core
Complex Care Manager RN embedded in primary care practices to develop multi-disciplinary care plans for patients with chronic conditions, focusing on social determinants of health and transitions of care.
Role type
Senior IC Registered Nurse (Complex Care Management)
Builds
Patient-centered care plans and coordinated care delivery for vulnerable populations
Domain
Healthcare / Primary Care / Population Health
Required skills
Comprehensive bio-psycho-social-spiritual assessment, chronic disease management, motivational interviewing, care plan implementation, interdisciplinary collaboration, triage of clinical changes, medication education, self-management skill building
Preferred skills
CCM Certification, BSN or Masters in Nursing, 2+ years clinical experience, experience with vulnerable populations, home care or clinic experience
Technologies
Electronic Health Records (implied by documentation standards), care management platforms
Responsibilities
Identify and recruit appropriate patients for care management; execute comprehensive assessments; collaborate with patients and care teams to develop care plans; implement care plans and assess goal completion; educate patients on medication conditions and self-management; triage and respond to clinical changes; collaborate with community partners and social workers; participate in local site operations and program planning; maintain HIPAA standards and confidentiality
Seniority
Mid-level to Senior, hands-on IC