REGISTERED NURSE CARE MANAGER PLUS

The RN Care Manager Plus, under the direction of the department Supervisor, is responsible for the deliberate organization of patient care activities between two or more participants (including the patient and/or family) involved in a patient's care to facilitate the appropriate delivery of health care services. Coordinates the delivery of care in collaboration with the multidisciplinary healthcare team within the practice setting and across health care settings to assess, evaluate, screen, and develop action plans to mediate gaps in care.

Assessment: Systematically collects comprehensive and focused data relating to health needs and concerns of a patient, group, or population as they move across the care Nursing Diagnosis and Outcomes Identification: Analyzes the assessment data to determine the diagnosis or issues to facilitate the appropriate level of care across the care continuum. Identifies expected outcomes specific to the patient, group, or population across the care Planning: Develops a patient- and/or population-centered plan of care that identifies and advocates for strategies and alternatives to attain expected outcomes based on funding resources, services, clinical standards, and outcomes. Provides consultation to influence identified plans of care, enhance the ability of other professionals, and effect Implementation: Implements the identified patient/family-centered care plan to attain expected outcomes in selected groups or Employs educational strategies for the patient, family or caregivers, and members of the healthcare delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made. Maintains objectivity in decision-making and utilizes facts to support decisions. Adheres to timelines provided by program guidelines and the care plans; follows department Standard Work Instructions. Evaluation: Evaluates the status and progress of the patient, group, or population toward the attainment of expected outcomes and communicates the status and progress to relevant professionals across the care Demonstrates an understanding of care management, complex disease management, transitions of care, post-acute care options, and community management standards. Demonstrates the knowledge and skills necessary to provide care for the physical, psychological, social, educational, and safety needs of the patients served regardless of age. Other duties as required