RN Care Manager

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

GENERAL PURPOSE This position manages clinical aspects of patient centered care including management of chronic conditions. This position works with the interdisciplinary medical team in the provision of patient care and development of program goals and initiatives.

Coordinates medical care of patients identified as high risk by health risk assessment/appraisal or by physician clinical determination. Assumes coordination role at the point of service through targeted outreach and follow-up. Assists in developing and implementing care plans for medically complex patients. Identifies barriers to a successful care management path. Identifies patient groups with chronic diseases. Assists in developing and implementing population-based strategies to close gaps in medical care. Identifies resources for patient self-management skills. Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan. Participates in program development by assisting with planning short-range and long-range program goals for chronic disease management. Assists with the development of current evidence-based protocols, policies, workflow/flow sheets, guidelines, etc. related to the provision of care within the medical home model. Participates in committees as assigned. Interacts effectively with physicians, home care team, patients, and their caregivers. Accountable for patient triage. Keeps abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature and maintaining professional contacts in the community. Other duties as assigned.