Details
Posted: 28-Apr-25
Location: Gainesville, Georgia
Job Category:
Nursing - Registered Nurse
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
The primary areas of focus for the HP2 Advanced Illness Program will include management of patients with multiple chronic conditions, including those complex health care needs identified by HP2. The Advanced Illness Program will support the patient's awareness and utilization of palliative and hospice services in coordination with their primary care physician. The population for the Advanced Illness program will be identified through predictive analytics and have diagnoses such as cancer, advanced heart disease or multiple chronic illnesses in advanced disease state. This program will be supported by registered nurses and social workers. The RN Care Manager will assist the HP2 network providers in applying systems, science, incentives, and information to improve medical practice and patient care, eliminate duplication, and reduce the need for medical services by helping patients and their support systems in managing medical conditions more effectively. The RN Care Manager will provide telephonic care and case management to members as part of a multidisciplinary care team. The RN Care Manager will offer members of HP2 health and disease education and empower them to actively participate in their care. Other duties of the RN Care Manager include, but are not limited to, consultation with members on their medications and durable medical equipment, review member care plans, address home care needs, and connect members to community resources; collaboration with primary care physicians and other providers to ensure there are no gaps in care; collaboration with members, providers, and care givers to ensure positive care outcomes. during care transitions. The RN Care Manager will provide evidence-based services to assist patients in achieving an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services. Care management services may be provided in a variety of settings including in-person, face-to-face encounters, by telephone, or electronic encounters such as telehealth visits.
Minimum Job Qualifications
Licensure or other certifications: Current Georgia RN license required. Current BLS certification required or must be obtained within 30 days of hire
Educational Requirements: Associates Degree
Minimum Experience: Minimum of one year experience in hospice or palliative care; two years minimum experience in health plan, health system, or home health care management; a minimum of one year experience providing care management within a primary care setting is required
Other:
Preferred Job Qualifications
Preferred Licensure or other certifications: Case Management Certification
Preferred Educational Requirements: BSN
Preferred Experience: Experience with discharge planning
Other:
Job Specific and Unique Knowledge, Skills and Abilities
High energy and ability to function effectively in a dynamic work environment.
Strong organizational and interpersonal skills; able to work effectively in a team environment.
Must be able to multi-task and prioritize on a daily basis.
Must be flexible and adaptive to a changing environment.
Must be proficient with computers, have the ability to type and talk simultaneously, and have excellent interpersonal and customer service skills, including telephone etiquette.
Excellent written and verbal communication skills.
Strong analytical and problem-solving skills; ability to review reports and complete data validation.
Excellent understanding of medical terminology and disease states.
Able to interpret complex regulations.
Maintains current continuing education appropriate to care management.
Demonstrated expertise with Microsoft Excel and reporting databases.
Essential Tasks and Responsibilities
Collaborates with providers in promoting the delivery of high quality medically appropriate care and services using fiscally responsible strategies.
Uses the nursing process to assess, plan, implement, and evaluate patient care and the use of resources.
Assists in the development, implementation, and analysis of a process for providing outreach to patients with identified care opportunities including, but not limited to, non-compliance, and maintaining clinical markers (e.g., blood pressure, HbA1c) within normal range.
Monitors the quality of care to ensure all aspects of services are safe and appropriate.
Make outbound calls to assess member's current health status.
Development of a patient centric care plan:
Provide patient education to assist with self-management
Identify gaps or barriers in treatment plans.
Educate members on disease processes
Coordinate care for members
Make referrals to outside sources
Coordinate services such as palliative, hospice, home health, and DME, as needed
Assist with advanced care planning
Tailors interventions that are multi-faceted, improve quality and cost effectiveness to meet the patient's need while respecting the patient's role as a decision maker in the care planning process:
Effectively uses the following tools/strategies that include, but are not limited to: evidence-based guidelines and practices, interactive care plan developed based on patient-set priorities where applicable, collaboration with multidisciplinary care teams, meet medical home (PCMH) requirements, physical/behavioral health integration, and patient self-management education and training.
Effective and timely adherence to disease specific, evidence based guidelines for all chronic conditions as well as preventative and curative care measures.
Improves overall patient care metrics as set by evidence practice medicine and recommended guidelines that are widely set for disease state/conditions that result in most health care expenditures as revealed in CMS chronic conditions literature and/or HP2 cost data (i.e., heart failure, diabetes, hypertension, COPD/Asthma, pneumonia, depression and stroke). Focus should minimally cover those patients with 4 or more chronic conditions.
Effectively and timely inform patients about their care planning and facilitate interaction among applicable care team members through application-based secure messaging, assessments, care planning and associated activities, and education.
Maintains awareness and understanding of patient resources from the NGHS, NGPG, the community, and payors to support care management, care coordination, and transitional care.
Anticipates needs of the patient population, identifying and developing programs to support care management, patient education and self-management activities.
Demonstrates reduced emergent/urgent care utilization and acute care readmissions, improved medication compliance, and adherence to diet/prescription regimens managed patients.
Assists in building an evidence base in terms of what works for complex and special needs populations through careful and consistent evaluation, measurement, testing, and analysis of interventions intended to improve quality and efficiency.
Ensure that discharged patients receive the necessary services and resources, including medication reconciliation.
Maintains current awareness and understanding of quality measures (e.g., HEDIS, Direct Contracting, pay for performance) and measures related to efficient utilization and cost.
Participates in the development/review/revision of standard work and related policies and/or procedures for Care Manager services.
Assists in identifying opportunities for system-collaboration, patient education materials, and/or other programs designed to meet patient population needs.
Coordinate care management efforts with network embedded care managers to ensure efficient collaboration and effective handoffs.
Assists in the identification of population health circumstances where standing orders do not exist, or exist but are not consistently utilized, for improving patient care outcomes.
Attends meetings with payors when patients being managed are discussed.
Encourage members to make healthy lifestyle changes
Document and track findings in a computerized system
Other duties as assigned.
Physical Demands
Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
Weight Carried: Up to 20 lbs, Occasionally 0-30% of time
Vision: Heavy, Constantly 66-100% of time
Kneeling/Stooping/Bending:
Standing/Walking:
Pushing/Pulling: Occasionally 0-30%
Intensity of Work: Frequently 31-65%
Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving
Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.
