RN - Care Manager - Lead
Company: SSM Health St. Anthony Hospital
Location: Oklahoma City
Posted on: July 14, 2019
Role Purpose: Assist with delegation of assignments, scheduling and
staff training. Provide care management and coordination activities
for the patients of the primary care practice. This includes
developing, providing and monitoring care management processes, as
well as, coordinating and supporting primary clinical teams with
these efforts. Identify high acuity patients and ensure care is
appropriately coordinated for this patient population. Triage
patients. Work with the practice manager and lead physician in the
practice to best serve the needs of the patient panel and the
primary care teams. Responsibilities:
- Assist supervisor with the delegation of assignments,
scheduling and staff training. Provide feedback during performance
- Work with designated clinical teams to provide care management
of patients, including pre-visit planning and post-visit summary
review. Assist patients in setting SMART goals for self-management,
teaching them self-management tasks. Report abnormal findings to
their physician team.
- Partner with physician leadership to define quality
measure/outcome reporting process and develop protocols and point
of care reminders using nationally recognized EBC measure/outcomes
(recommend starting with three clinically important
- Manage assigned panel of chronic care (high acuity) patients by
developing relationships with the patient and providing follow-up
contact to ensure compliance with recommendations (i.e.
medications, lab/x-ray, specialist visits, PCP visits, dieticians,
CDE, etc.). Manage referrals to specialists, hospitalizations, ER
visits, ancillary testing, and other enabling services.
- Provide telephone advice per protocol and handle urgent calls
and emergent calls.
- Work with patient's care team to coordinate change readiness,
needs assessment and develop an individualized treatment care plan.
Collaborate with the patient, physician, and other care team
members in assessing the patient's progress toward individual
health care goals. Assess barriers when patient has not met
treatments goals, is not following treatment plan of care, or has
not kept important appointments and work with care team to
determine next steps.
- Serve as a resource to clinical staff and providers to
establish quality goals using reports. Oversee the development,
procurement, and adoption of patient self-management educational
resources used by the primary clinical teams. Collaborate with
payer Case Managers for additional services when appropriate.
- Develop a list of medical supply and community resources
available to patients and maintains collegial relationships with
the entities used most frequently.
- Work with appropriate parties to coordinate efficient consult
request communication and consistent documentation of patient
self-management measures which entails a mutually agreed upon care
plan that is efficiently available to all and reporting of progress
- Partner with consulting physicians, hospitals, ER and other
frequently used healthcare resources to clarify roles, develop
effective, efficient timely communication between PCP and these
entities. Facilitate physician leadership to develop written
agreements with consulting physicians and key facilities to define
the roles and method of communication. Develop workflows and
protocols within the PCP that ensure ER, hospital follow-up. Work
with IT resources to facilitate registry reporting at the site &
documentation of EBC in searchable fields.
- Perform other related duties as assigned that correspond to the
overall function of this position. Minimum Qualifications:
- Licensed by the Oklahoma Board of Nursing as a Registered
- Three (3) years of experience as a registered nurse.
- Current CPR (Healthcare Provider). Preferred Qualifications:
- Certified in Care Coordination and Transition Management
(CCCTM) by the Medical-Surgical Nursing Certification Board (MSNCB)
- Home care clinical experience preferred. Physical Requirements:
Employees in this position are, or can be, required to possess the
following physical capabilities:
- Lifting, carrying, pushing and/or pulling up to 100 lbs.
- Stooping, kneeling and/or crouching daily
- Standing or walking more than 3 hours a day
- Reaching, grasping, fingering, and/or feeling more than 5 hours
- Visual acuity in order to correctly distinguish skin tone
variations, evidence of IV infiltration, infection; able to read
telemetry, blood pressure gauges, etc.
- Audio acuity in order to correctly distinguish various body
sounds (i.e., respirations, heart tones, bowel sounds).
- Audio acuity to discern sounds made by various types of
machinery or equipment that would indicate dangerous or improper
operation St. Anthony Hospital - St. Anthony Hospital is a 601-bed
regional referral facility specializing in cardiology, oncology,
surgery and behavioral medicine. The hospital, established in 1898,
is located in Midtown Oklahoma City and serves the needs of Central
Oklahoma, as well as many counties throughout Oklahoma, through its
large rural affiliate network of hospitals. Four St. Anthony
Healthplex campuses provide convenient emergency and outpatient
service access to the outlying communities of the metropolitan
area. St. Anthony added urgent care services in May 2015 at St.
Anthony North. St. Anthony has received numerous awards including
the Oklahoma Quality Award for Excellence, Certified Healthy
Business, Premier QUEST-- Award for High-value Healthcare Citation
of Merit, among others. Healthsights ranks St. Anthony at
performance levels for quality and patient satisfaction higher than
local competitors and many national health care organizations.
Keywords: SSM Health St. Anthony Hospital, Oklahoma City , RN - Care Manager - Lead, Executive , Oklahoma City, Oklahoma
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