Care Manager - RN

Partnership for Community Care
Reidsville, NC, US
Jan 06, 2019
Feb 06, 2019
Managed Care
Contract Type
Job Description

The RN Care Manager will:

  • Complete initial assessment/Comprehensive Health Assessment tool in CMIS to evaluate patient needs, update health information, complete screenings, determine appropriate interventions, and set achievable patient-centric goals based on the individualized plan of care. Assess, Screen and evaluate care management process for individual based on the acuity of need and level of case management
  • Outreach to patients with multicultural and diverse socioeconomic backgrounds, who have chosen Carolina Access II providers within the Partnership for Community Care Network
  • Conduct face to face encounters with patients in their homes, at providers offices, and in various other community settings, in regards to identifying barriers that prevent the patient from securing appropriate care in the patient centered medical home
  • Review data and claims provided by CCNC data sources to identify and determine appropriateness for Care management, which includes monitoring utilization, reporting, and compliance issues
  • Develop, monitor and evaluate, with members of the Care team, medical and psychosocial plans of care for the patient that requires coordination of care from various providers in the community, through ongoing review of medical records, telephone contact, home visits, community encounters, consultation with medical providers
  • Medication reconciliation with initial contact, hospital admissions, and ongoing throughout Case management process
  • Maintain current and ongoing records of all case management tasks and activities in the CMIS program to assist CAII in securing accurate statistical data
  • Encourage, Empower and Educate patient to the self- responsibilities of chronic disease management utilizing network provided self- management tools and approved best practice models based on CCNC guidelines
  • Effectively manage a case load with assigned status of Heavy and Medium, as defined by the CCNC Care management Standardized Plan
  • Maintain and appropriately document confidential HPI of patients, in a timely manner, in Case Management Information System (CMIS)
  • Leads and works collaboratively with Multi-disciplinary team members to facilitate patient- centric care plans, incorporating disease management practices, according to CCNC standards
  • Participate and attend staff, medical management, workgroup, community collaborative, and interdisciplinary team, meetings as identified
  • Coordinate and provide Case management services with guidance and collaboration from Primary Care Providers
  • Maintain current professional continuing education and license renewal
  • Ability to work autonomously and utilize functional time management skills to meet program needs
  • Communicate openly and professionally with patients, providers, multidisciplinary care team members, as well as administrative staff in the healthcare setting
  • All other duties as assigned


  • RN Degree, BSN preferably
  • 2 years Case management experience highly preferred
  • State licensure
  • Computer experience - Word, Excel, web-based patient programs, Outlook

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