Northwell Health Registered Nurse (RN) / Field Care Manager - Transitional Care / Nassau in Manhasset, New York

Req Number 001D7J

Job Category Case Management

Job Description

RN in this position will be traveling to meet with patients at the home and in the Hospital setting throughout the Nassau region to perform risk based assessments, to see if patients meet the criteria to enter our transitional care program.

Works with members, family, caregivers and providers in identifying and evaluating patient needs and provides guidance and education. Promotes self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Provides high risk patients with chronic disease management and liaises between patient, hospital, physicians’ office, home care agency, etc. Works to reduce medical complications through identified high risk triggers, compliance with medical appointments and community based care.

  1. Formulates and implements a care management plan that addresses members identified needs by assessing member/family needs, issues, resources and care goals.

  2. Utilizes Telehealth to enhance members’ access to care and to improve clinical outcomes.

  3. Identifies and effectively utilizes community resources to help meet the needs of member/families.

  4. Promotes member self-management and empowers member/families to achieve maximum levels of wellness and independence.

  5. Encourages members to identify, develop and utilize their support systems.

  6. Communicates with members, family, providers and plan staff to coordinate patient care.

  7. Performs outbound calls to specific patient population. Re-enforce discharge plan, medication management, provide patient and family education.

  8. Directs patient to the proper locus of care including follow-up and self home care based on outcomes of nursing assessment.

  9. Participates in education and in-service programs.

  10. Provides patients with clear instructions and education utilizing appropriate guidelines.

  11. Performs related duties, as required.

Qualifications

• Graduate from an accredited School of Nursing. Bachelor’s Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN Degree within five (5) years of employment date.

• Current license to practice as a Registered Professional Nurse in New York State.

• Case Manager Certification (CCM), preferred.

• Minimum of three (3) years experience in two (2) or more of the following areas: supportive counseling, case management, clinical call center setting, discharge planning, advocacy, outreach, screening, information and referral.

• Experience working with Electronic Health Record (EHR), preferred.

• Demonstrates progressive proficiency with the utilization of available computer technology, including typing skills.

Demonstrated customer service, leadership, communication, interpersonal and problem solving skills, required. Sensitive to cultural diversity and low literacy issues in care provision.