SUMMARY:

30 hours a week (6-8 hours a day) as scheduled

The Nurse Care Manager reports to the Director of Quality Programs for the Division of Kidney Disease and Hypertension.   Under the general supervision of the Director of Quality Programs for the Division of Kidney Disease and Hypertension, Practice Physician Medical Director, and departmental policies, the Nurse Care Manager works on an interdisciplinary healthcare team in a specialty care setting to conduct direct patient care and quality improvement activities. He/she will be part of a program charged with implementing strategies to meet specified quality measures.

The Nurse Care Manager is responsible for providing comprehensive screenings, assessments, care coordination services, disease education, and self-management support to patients with chronic kidney disease. The Nurse Care Manager is integrated into the office-based healthcare team to promote patient-centered care, frequent contact with primary care providers, and dialysis centers. The Nurse Care Manager has a key role in educating patients about kidney replacement therapy, transplant, palliative care, hospice, and preparing the patient for their chosen modality. The Nurse Care Manager is also responsible for preventing hospitalizations in the dialysis population and patients identified as at risk for rapid progression of advanced kidney disease. Patient care activities will be conducted in person as well as via telehealth.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect, and Excellence as these guide our everyday actions with patients, customers and one another.

• Works collaboratively with the care team to identify and case manage patients with a high risk of adverse health outcomes ensuring open communication patient status with providers and office staff.
• Sets up and implements patient-centered care and administers evidence-based healthcare, utilizing innovative thinking and understanding of healthcare delivery system access points and services.
• Facilitates communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the patients’ total health and attaining desired patient outcomes.
• Provides comprehensive screenings, assessments, care coordination services, disease education and self-management support with patients who have chronic health conditions, with particular attention to chronic kidney disease, hypertension, diabetes, and depression in the office or home setting as needed.
• Provides detailed education to patients about their specific chronic illness, including pathology signs and symptoms, complications and medications used in treatment.
• Conducts and/or reviews medication reconciliation and works with provider/team pharmacist as needed to assist with medication management to support patients to enhance medication adherence.
• Works one-on-one with patients meeting individual healthcare needs; develops a plan of care, interventions and treatment goals with patients that promote improved health outcomes and quality of life and reviews with provider and clinical team members.
• Addresses barriers to optimum patient health; advocate for patients to ensure access and timely service delivery across the continuum of care.
• Ensures safe, effective and efficient care for all patients transferring to home from the Emergency Department; responsible for timely telephonic follow up of complex patients who present to the ED.
• Utilizes behavior techniques, such as motivational interviewing, to assist patients with establishing self-management goals and action plans with timeframes.
• Acting as a liaison, coordinates care and performs outreach identifying and utilizing cultural and community resources; providing access to culturally and linguistically appropriate services as needed.
• Utilizes an interdisciplinary team approach to address opportunities to plan and coordinate care; acts in a supportive capacity to other team members (medical assistants, patient service representatives, practice managers, providers, etc.) in supporting patients and their treatment plan.
• Utilizes the Electronic Medical Record (EMR), chronic disease registry, and other reporting tools as directed to prioritize patient follow-up.
• Generates quarterly reports on service volume, distribution of patients by plan, and types of services provided; analyzes data and develops and implements performance improvement strategies to meet and exceed quality of care expectations.
• Maintains knowledge of contemporary, professional nursing practice within the legal framework of Rhode Island Nurse Practice Act.
• Attends training and retraining as needed, to maintain current knowledge of patient’s care practices and procedures.
• Shares best practices among all teams, services as a medical home advocate and advisor, leads by example to support a positive work environment and encourages all staff to do the same.
• Participates in establishing protocols, risk management activities, practice performance improvement initiatives and quality measures with interdisciplinary team.
• Maintains a safety, environmental and infection control in accordance with Brown University Health policies, procedures and objectives.
• Maintains a safe environment for patients, visitors and staff.
• Performs other related duties as assigned.

EDUCATION:

• Baccalaureate in Nursing (BSN) preferred

LICENSES/CERTIFICATIONS:

• Current license to practice as a Registered Nurse in the State of Rhode Island.
• Current AHA BLS required.
• Receipt of certified diabetes outpatient education (CDOE/CVDOE) or willingness to obtain this certification within 2 years of hiring. 

EXPERIENCE/SKILLS:

• Minimum Three (3) years experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
• Experience working with primary care providers to coordinate care and disease management.
• Experience working with CKD/ dialysis patients regarding their care coordination and disease management / education is preferred.
• Demonstrates knowledge and skills necessary to provide care to patients with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
• Ability to work independently and collaboratively to achieve goals.
• Highly organized and detailed.
• Exercise sound judgment and decision-making.
• Able to assess and differentiate priorities.
• Excellent interpersonal skills and ability to work with and through people to get the job done.
• Excellent written and verbal communication skills.
• Able to maintain confidentiality with all aspects of information (including patient data) in accordance with the practice’s philosophy and policy, and state and federal regulations. Must handle the most sensitive and confidential matters with the utmost discretion.
• Proficiency with computer skills (i.e., Microsoft Word, Excel and Access, and Web-based applications).

SUPERVISORY RESPONSIBILITY:

None

Pay Range:

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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