Registered Nurse (RN) Care Manager

The Registered Nurse (RN) Care Manager will be responsible for a panel of patients and will work in conjunction with the Strive nurse practitioners to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. Acts as a resource for patients and their families, the local care team, and other healthcare professionals. Services to patients are generally provided telephonically but there may be programs where on-site visits to clinics, medical offices, hospitals, or visits to patient homes are required.

This position is a combination of a remote and in person role. Face to face meetings with peers and leadership may be required.

Essential Functions

• Collaborates with the care team to develop an individualized and comprehensive care plan for the patient
• Proactively contacts the patient and/or clinic on a frequent basis as specified in the program details to assess their situation, aid, and answer questions as necessary
• Manages a panel of patients with a range of acuity levels and complexity.
• Demonstrates case management knowledge and adherence with NCQA measures for complex case management
• Create, revise, and update the patient-centered care plan to help patients achieve individual self-management goals

• Provides updates to care team and family members. Identifies patient knowledge deficits regarding current health situation.
• Provides the appropriate education, support, and materials to facilitate informed decision-making and understanding
• Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention
• Oversite of non-clinical staff members supporting patient care
• Serves as a liaison with dialysis facilities, providing care plan updates to help streamline the transitions in care maintains and updates the appropriate program software to manage and record required information and data
• Generates and analyzes reports via Strive data portals for management, identification of trends, anomalies, and focus areas
• Adheres to company and clinical guidelines to identify, review, assess, and allocate patients for program participation according to their identified needs
• Participates in process improvement activities
• Delivers care in a culturally sensitive way
• Collaborates with all levels of the clinical team to improve processes, communication, and team dynamics required to provide the best care to our patients. Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program
• Participates in after hours on call program
• Delivers care in both the home and clinical settings

Minimum Qualifications

• BSN or MSN degree from accredited school of nursing required or equivalent
• Current Registered Nurse (RN) license in the state of practice required
• Minimum of 5 years’ experience in clinical nursing required
• Current BLS certification required

Preferred Qualifications

• Excels at developing strong patient and family relationships that foster engagement and best outcomes for all aspects of Strive Health’s Model of Care
• Minimum of 3 years’ experience in nephrology, ER, ICU, Cardiac, or Ambulatory Complex case management nursing preferred
• Certified Case Manger
• Demonstrated knowledge and understanding of data and managing clinical, financial, and patient satisfaction outcomes
• Demonstrated experience and effectiveness in a change agent role
• Proficiency with documenting and navigating electronic medical records (EMR)
• Strong computer skills and proficiency in MS Word and Outlook required

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