Care Manager Registered Nurse - Atrium Health Remote PT Weekends

Atrium Health is a nationally recognized leader in shaping health outcomes through innovative research, education and compassionate patient care. Atrium Health is an integrated, nonprofit health system with nearly 70,000 teammates serving patients at 37 hospitals and more than 1,350 care locations. It provides care under the Wake Forest Baptist Health name in the Winston-Salem, North Carolina, region and Atrium Health Navicent in Georgia. Atrium Health is renowned for its top-ranked pediatric, cancer and heart care, as well as organ transplants, burn treatments and specialized musculoskeletal programs. A recognized leader in experiential medical education and groundbreaking research, Wake Forest School of Medicine is the academic core of the enterprise, including Wake Forest Innovations, which is advancing new medical technologies and biomedical discoveries. Atrium Health is also a leading-edge innovator in virtual care and mobile medicine, providing care close to home and in the home. Ranked among U.S. News & World Report’s Best Hospitals for cancer treatment and in eight pediatric specialties, Atrium Health has also received the American Hospital Association’s Quest for Quality Prize and was the recipient of the 2020 Centers for Medicare & Medicaid Services Health Equity Award for its efforts to reduce racial and ethnic disparities in care. With a commitment to every community it serves, Atrium Health seeks to improve health, elevate hope and advance healing – for all, providing more than $2 billion per year in free and uncompensated care and other community benefits

Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes. Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team. Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources. Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan. Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements. Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs. Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care. Coordinates referrals to other internal AAH departments and/or external community resources as necessary. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.