Clinic RN Care Manager oversees patient care management and day to day clinic administrative duties. This position will assist with overseeing the medical assistants within the Primary Care Team and providing direct case management for high risk and complex patients assigned by the primary care providers. The goal of the case manager is to develop and assist the medical team in developing a trusting relationship with their patients to accomplish health and wellness goals, encourage informed decisions on and improve the quality of the care prescribed, and improve overall quality of life.
In addition to Case Management duties it is the responsibility of the care manager to ensure the Medical and Wellness Center runs smoothly, performs necessary and assigned administrative duties, and acts as clinic registered nurse providing assistance and care as assigned to established patients of the center.
Essential Duties and Responsibilities
Clinic RN Care Manager
Function as a point of contact, advocate, and informational resource for high risk patients, care team, and family/caregiver(s), payers, and community resources.
With license scope of practice support non licensed staff in Care Coordination tasks and give direction
Ensure that high risk patients receive the care they need, and that they understand their medical condition, medications, and other instructions.
Assess patient’s unmet health and social needs
Implement and coordinate the provider-developed care plan with the patient, family/caregiver(s) and providers
Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
Contact patients to discuss treatment, progress, and/or actions needed, including medication refills, lab tests, specialty referrals, and imaging
Assess and address motivational and psycho-social issues
Coordinate with Health Coaches, or any other approved resources, any individual health education and risk reduction interventions recommended by the lead physician
Help promote timely access to appropriate care and increase utilization of preventative care.
Maximize access to available resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
Assist with the identification of “high-risk” patients.
Understand and deliver the established model of care
Responsible for the daily communication, coordination, and implementation of all medical needs of their patients, as directed by the lead physician
Responsible for the organization of clinic high-risk patient population and their population management documents
Assist in treatment of high risk patients by encouraging them to remain committed to their doctor and nurse assessed program
Ensure smooth patient flow, timely care, and outstanding customer service for patients
Assist the care team in executing the comprehensive care plan for patients
Continually assess and proactively seeking out potential issues in patients pursuant to the care team.
Responsible for presenting patient information at all huddles with the Primary Care Team.
Work with patients and their families to ensure compliance to treatment plan
Educate, coordinate, and encourage patient compliance by regular interactions
Perform other duties as assigned
Participate in outreach
Maintains the confidentiality of patient information
Clinic RN Team Support:
Work with the Senior Team Lead and Team to design and deliver the highest quality care
Understand and support our model of care and medical guidelines
Ensure smooth patient flow, timely care, and outstanding customer service for patients
Establish relationships with hospitals and emergency department providers, etc. as well as manage relationships with external vendors
Help administrative responsibilities such as:
Maintain nursing operations by updating policies and procedures including but not limited to care management, patient flow, emergency, and outreach workflows
Support personnel policies and procedures and manage staff education
Assist with Recruitment, orientation, and training of positions as needed on the Care Team.
Maintain a safe and clean work environment with regional support
Ensure operation of medical and office equipment by completing maintenance requirements
Assist with monthly reporting of Quality Assurance Initiatives as directed by the Senior Team Lead
Support clinic team in day to day tasks and activities including daily resources to prioritize workload and navigation of systems for patient populations
Be available to assist front office and medical assistant when needed in all areas including but not limited to:
Scheduling patients and ensuring patient satisfaction
Managing medical records and confidential documents
Responding to phone and email messages in a timely manner, redirecting calls as needed
Triaging walk in patients as needed
Assisting Care Team with calls, specialty appointments, and follow ups
Ordering medical and office supplies, providing billing support, and maintaining medical and office supplies inventory while managing budget and expenses.
Current state RN license in good standing or in the process of obtaining licensure
2-3 years of nursing experience with Primary Practice preferred but other applicable experience considered.
Ability to effectively carry out plans as directed by Senior Team Lead
Proven ability to deliver excellent customer service
Comfortable in urgent care and primary medical clinic settings
Focus on excellent medical care
Interested in being at the forefront of changing the current health care system
Able to deal with uncertainty and adapt to change in a positive manner
Core values consistent with a patient and family centered approach to care
Enthusiastic and compassionate
Demonstrates a positive attitude and proven ability to deliver respectful, professional customer service
Excellent communication skills including verbal, listening and written.
Excellent organizational skills (managing multiple complex issues for many patients and continually following through on multiple tasks)
Highly flexible, able to adapt to change, and overall understanding (developing a new and unique healthcare model with many changes)
Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns
Recognizes and willingly accepts opportunities for improvement with all aspects of position and to learn new skills
Proactively educates self on providing quality care and improving professional skills
Thinks critically, utilizes sound judgement, and promptly reports potential patient safety risks to responsible professionals/care team
Ability to effectively work with and through physicians, customers, and other members of the team in a cooperative and collaborative manner in order to improve clinical quality outcomes
Technologically adept and proficient in Microsoft Office, electronic medical records, office telephones, copy equipment, and other equipment
Maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
Bilingual English/Spanish proficiency required
Internal Number: WFM20200915CCRN
About Whole Foods Market
Whole Foods was founded in 1980 on the belief that where food comes from, and how it’s grown, matters. It meant creating quality standards, working with suppliers who achieve them, and sharing that information with our customers. And it radically changed the way people understood and shopped for food. The result has been the highest quality natural and organic products, an unmatched experience in more than 500+ stores, with a passionate team of over 90,000 team members, 5 percent of our total net profits given back to our communities each year, and millions of customers who put their trust in us every day.Whole Foods Market (WFM) has created a new and comprehensive model of medical care that aims to put our Team Members first and provide the highest quality care for both them and their families. Within the Medical and Wellness Centers, Whole Foods now provides a support team to walk with Team Members throughout the journey from health to illness and back to health again. This personalized care team will follow Team Members through the primary medical care setting, to high risk medical care and specialists, even to hospitalizations if indicated. At our Medical and Wellness Centers e...ach Whole Foods Team or Family Member is assigned to a Primary Care Team comprised of a primary care physician and a care coordinator/medical assistant.