RN Care Manager, full time, days, local travel for Emtiro Health in Winston-Salem
The Emtiro Health Nurse Care Manager, utilizing the care management process as an integrated member of a multi-disciplinary care team, will work closely with adult patients, pediatric patients/family, the primary care physician, and the health care team to help ensure that patients receive comprehensive and coordinated care. The Nurse Care Manager is an integral member of the Care Team, who conducts comprehensive clinical assessments, develops a patient-centric care plan, and engages the patient and family through coaching, with the focus of preventing admissions, readmissions, and adverse events. The Nurse Care Manager assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/family and other members of the health care team. The Care Manager communicates and collaborates with the patient’s primary and specialty healthcare providers to provide well-coordinated care. The Care Manager ensures that patients receive care that is respectful of and responsive to individual patient preferences, needs, and values.
Education and Experience
- Graduate from an accredited School of Nursing (RN). Minimum of 1 year of nursing experience in a clinical setting
- Experience in case management and/or care coordination preferred
Licensure and Certification
- Actively licensed by North Carolina as a Registered Nurse.
- Valid North Carolina driver license
- CCM (Certified Case Manager) preferred or willingness to obtain certification within the first 12 months of hire.
1. Utilizes targeted reports and real-time referrals to identify patients who may benefit from care management services.
2. Performs patient assessments to identify and prioritize patient?s medical and behavioral health conditions, and health system and social determinant needs while also identifying patients? knowledge gaps.
3. Completes in-home safety assessment and addresses specific safety risks, as required. Establishes goals that are patient specific and identified as part of the patient?s self-management goals. Develops patient-centered care plans with the patient/family that considers medical, mental, emotional, spiritual, social, cultural, relational, contextual and environmental aspects, providing all information to the PCP. Sets an appropriate timeline for achieving identified goals. Updates the patient care plan as changes in status occur and communicates with the PCP and other members of the treatment team, as indicated.
4. Coordinates all aspects of care for patients through the continuum, including physical health, behavioral health, and social needs. Coordinates transitions of care between clinical settings. Conducts medication reconciliation and provides education, and consults with pharmacist, as needed.
5. Facilitates communication and collaboration among payors, providers, and community agencies to meet the needs of patients/families and promote continuity of care.
6. Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with utmost attention to service.
7. Considers the developmental needs of all ages of patients throughout the continuum of life and adjusts care to those needs. Provides phone calls to reinforce education, ensures movement towards reaching goals, and promotes self-management, while utilizing identified teaching materials and evidence based best practices. Utilizes telemonitoring equipment to support wellness when indicated and as available. Documents assessments, screenings, tasks, interventions, goals, care plans, and medication management in the appropriate database, per department policy and national accreditation guidelines.
8. Acts as a resource to staff, works on a case-by-case basis to coach and mentor on techniques, and approaches to management of psychosocial issues in a high-risk population. Provides short-term crisis intervention support and education for patients, as needed. Makes appropriate referrals for ongoing needs.
9. Delegates tasks and oversees the work of a Care Management Associate who assists in the management of patients. Maintains collaborative, team relationships with peers and colleagues, and helps foster a positive work environment, including working collaboratively with Emtiro staff and all affiliated organizations.
10. Demonstrates the ability to function in a professional setting through active participation in a professional care team environment. This includes participating in team meetings, adherence to care coordination standards and principles, professional development and growth, autonomous practice, acknowledgment of accountability for actions, and critical thinking.
11. Maintains good understanding of chronic disease, behavioral health diagnoses, evidence-based treatment and management, motivational interviewing techniques, and applies these principles in the care management services provided to patients.
12. Completes annual trainings and competencies. Attends staff meetings and continuing education programs related to program goals.
13. Embraces innovation and adapts to various technology platforms.
14. Commitment to continual growth as an individual and as a member of an innovative and growing organization, including embracing new initiatives.
To apply for this position, please click on the "Apply Now" button on this page. You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".
Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-6464. Office hours are Monday-Friday, 8:00am-5:00pm.
If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at email@example.com.
It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.