DaVita RN Care Manager - Affiliates in Las Vegas, Nevada
PLEASE NOTE THIS ROLE IS BASED IN OUR AFFILIATE CLINICS
Responsible for performing patient-oriented care management, disease management and care coordination through transitions of care either at an outpatient clinic location and/or telephonically. Utilizes the nursing process to complete assessment and care planning. Collaborates with interdisciplinary care teams to promote quality of life and patient’s self-management of chronic disease. Provides evaluation of patient needs and knows where to find resources for patients and actively educates patients on their disease states.
Acts as an RN liaison between Healthcare Partners (HCP) and Affiliate Clinic providers and staff to communicate and engage them in care coordination and quality improvement activities
Completes appropriate assessments and generates individualized plan of care.
Implements and monitors plan of care with goal to stabilize and resolve problems.
Provides patient education on medical condition/disease.
Able to perform medication reconciliation with patients and notifies clinician of any discrepancies. Provide coordination of care for the patients in various settings.
Identifies and enrolls patients in Care/Disease Management Programs appropriately.
Coordinates care with central departments on assigned patient caseload, including out-of-area, inpatient, post-acute, outpatient and specialties.
Coordinates care with outside vendors and network providers.
Adheres to all timelines for patient follow ups and interventions as set.
Ensure appropriate documentation that meets quality and regulatory standards.
Participates in clinical rounds with physician and medical leadership and able to present patient cases accurately.
Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of reports and systems such as Health Plan Benefits, Division of Financial Responsibility (DOFR), utilization of metrics and CM reports.
Able to educate patients, patient’s family and care givers on effective ways to promote health and affect disease state.
Adheres to departmental policies and procedures as approved by the Medical Executive Committee (MEC)and Office of the Chief Medical Officer (OCMO)
Coordinates provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care and ensures smooth transition back to the Primary Care Provider.
Addresses medical and non-medical variances/quality identifies and accurately documents and reports according to company policy and procedures.
Promotes alternative care programs and researches available options including costs and appropriateness of patient placement; recommends coordinates and educates patients and providers on these options.
Attends all assigned Care Management meetings and reports on patient status as defined by the region.
Attends all assigned educational meetings to ensure compliance within scope of practice and ensuring up to date with current practice.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
At least one year of experience in clinical setting demonstrating the ability to assess, document and implement the nursing care plan.
Preferred: Previous care management, utilization review or discharge
Preferred: Planning experience preferred.
Graduate from an accredited school of Nursing.
Current state RN license.
Bachelor’s degree in Nursing preferred.
Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
Knowledge, Skills, and Abilities
Knowledge of current standards of patient care.
Thorough understanding of RN scope of practice.
Manual dexterity to use/handle equipment and instruments.
Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.
Ability to make sound, independent judgments and act professionally under pressure.
Valid driver’s license, insurance and vehicle for work-related travel.