Care Management RN - Comprehensive Care

The Care Manager, RN manages care for high risk, chronically and acutely ill patients by collaborating with the Comprehensive Care team to monitor care and treatment of patients. 

• Full-Time/Full Benefits eligible


• Monday-Friday - 8:00am-4:30pm


• Canal Winchester, OH

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Participate in taking care of high risk, chronically or acutely ill patients.


• Perform complete assessment of patient's current health status, including barriers to achieving optimal health, and available Identify potential gaps in care based on the assessment.


• Participate in the development and creation of an initial plan of care and self-management plan that highlights potential opportunities for improving clinical outcomes and/or utilization patterns. Collaborate with care team, patients, and caregivers to achieve plan of care outcomes and improve patient outcomes.


• Facilitate and monitor the developed plan of care for patients. Work with Comprehensive Care team to manage caseloads.


• Coordinate patient/family/caregiver participation in plan of care and self- Coordinate patient education to achieve plan of care using evidence-based methods.


• Perform Face-to-Face visits as necessary including home, office, and skilled rehab facility settings. Evaluate barriers to attainment of self-management goals and develop strategies to


• Provide ongoing feedback to patient primary care team through regular communication.


• Work in collaboration with inpatient, ambulatory, and community partners to facilitate continuity of


• Facilitate referrals to other disciplines, COPC resources, or community-based programs to improve patient


• Communicate with patients via phone calls or during scheduled home visits promptly. Conduct end-of-life discussions with patient/ family, as


• Document in the medical record and designated case management tool to accurately  reflect collaborative care planning, interventions and evaluation against defined targets and

Experience, Education, Licensures & Certifications

• Required: 5 or more years of clinical and case management experience in a hospital, home health/hospice, or managed care setting


• Required: Active Ohio RN license


• Required: Active Ohio driver’s license with the ability to travel throughout  COPC’s service area.


• Preferred: CCM certification; Bachelor's degree in nursing

Knowledge, Skills & Abilities

• Must be able to perform any clinical or clerical duty as assigned skillfully.


• Must demonstrate the ability to handle stressful situations appropriately.


• Must be able to work flexible hours as needed.


• Must demonstrate ability to manage case load and document progress in a timely way as outlined by the care program assigned to each patient.


• Must maintain patient confidentiality.


• Must demonstrate a proficient driving record and up to date auto insurance as travel to visit patients is necessary.


• Knowledge of chronic and acute disease states in adults


• Knowledge of common medications used in a primary care setting including indications, dosages, and side effects.


• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management, and quality improvement.


• Proficient in computer software and usage including Microsoft Outlook and Microsoft Excel.


• Strong analytical, organizational, and time management skills.


• Ability to work independently and within a team environment with minimum supervision.


• Ability to demonstrate work toward the progress of patient-centered goals.


• Ability to develop and maintain rapport among health care professionals within individual COPC practices.


• Ability to adapt to changing environment.


• Ability to administer IM medication


• Ability to perform straight or indwelling catheter procedures, blood draw, nebulizer treatment, etc. as necessary


• Ability to provide same day or next day Home Visit’s for assessment as needed (ie., lab specimen collection, education, and treatment plans adjustments with collaboration providers.


• Excellent written and verbal communication skills; ability to communicate effectively in stressful situations.


• Self-disciplined, energetic, passionate, and innovative.


• Decision making/problem solving skills.


• Critical and ‘systems' thinker.


• Strong attention to detail.


• Training/teaching skills.


• Demonstrate awareness and ability to work alongside diverse cultures and patient populations.


• Commitment to customer service.