Case Manager RN

Grants RN Care Manager

The Grants RN Care Manager works with the grants healthcare team to implement a tailored program for each patient based on specific clinical risk factors and preferences. The Grants RN Care Manager is responsible for conducting tailored research care plans for each patient based on individual needs and primary care physician (PCP) advice. This role involves ongoing communication with involved providers regarding care plans and changes in condition to ensure continuity of care. The Grants RN Care Manager will also be responsible for identifying and coordinating referrals to resources within the healthcare system, home health services, community-based prevention, and other relevant programs.

Job Description

• Conduct structured assessments of patients in the study and develop and implement individualized care plans using study protocols.
• Engage patients and caregivers in self-management using motivational interviewing.
• Communicate care plans and any changes in condition to primary care physician and healthcare team.
• Conduct in-person clinical visits to discuss patient and family members' priorities and answer questions about problems, resources, and implementing care plans.
• Provide telephone follow-up to monitor implementation of care plans and support patient self-management; facilitate appointments with providers; refer, when appropriate, to home health agencies and local community-based organizations for services and materials while maintaining close working relationships with these organizations.
• Periodically reassess clinical risk factors and revise care plans accordingly.
• Maintain clinical information using care management software system.
• Participate in quality improvement efforts for the PHSO grants program.
• Assist with grants committee planning and support.
• Document and report program goals and deliverables as required.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.