Care Manager RN

The William F. Ryan Community Health Network is a group of not-for-profit, Federally Qualified
Health Centers that delivers high quality, affordable and comprehensive medical care to diverse and underserved communities. We are currently seeking a Care Manager RN for our Ryan-NENA Community Health Center, a Joint Commission/NCQA-PCMH accredited primary care medical facility in Lower Manhattan.

Position Overview:
Care Coordination, Care Management and Transitions of Care

The Care Manager, RN is an integral member of the Center’s primary care practice teams and is responsible for providing care coordination and care management services to patients who are at risk for poor outcomes, health deterioration, co-morbidities and preventable hospitalizations. This includes coordinating and managing the care of chronically ill patients, and ensuring that patients receive optimal care in relation to acute illness management, chronic disease management, and preventive care across multiple health settings and with various multiple physicians/providers. This work is carried out in support of the mission and goals of Ryan Network.

Essential Functions:

  • Patient care coordination and care management, including care transitions; referrals; report management; and two-way communication between the Primary Care Physician (PCP), specialists, and other providers.
  • Focus on care management of patients identified by the PCP team who are at highest risk to decrease hospital and emergency room (ER) utilization and improve health outcomes.
  • Evaluate appropriate follow-up care for patients at medium and high risk for health deterioration, sentinel events, and/or poor outcomes, and develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.
  • Comprehensively assess patient’s physical, mental and psychosocial needs, and assist patients in solving issues related to the health care system, financial and psychosocial barriers. Utilize behavioral strategies to assist patients in adopting health behaviors, improving self-care and managing chronic disease.
  • Integrate the patient/family into care coordination and care management planning and communications, assuring that the patient/family are informed and supported in decision-making.
  • Ensure transition of care for patients discharged from the hospital or ER within 24 – 48 hours to prevent readmission and related complications. Evaluate and provide appropriate follow-up care for recently discharged patients to prevent further disease exacerbation, complications, or additional ER or hospital utilization.
  • Use data from the electronic health record to determine patients at highest risk for health deterioration, sentinel events, and/or poor outcomes.
  • Provide timely and ongoing communication with the PCP and practice team regarding their highest risk patients to maximize the management of patient needs and ensure that risk reduction activities are incorporated into the care plan.
  • Coordinate care with other care managers (home health care, case managers, etc.) and with specialists to maximize care and promote patient safety.
  • Clinic Patient Care

  • Assist with day-to-day patient care activities and tasks as needed, including those seeking same day services. These will include but are not limited to: processing PCP forms such as prior authorization (PA), M11Q, home care orders, transportation and durable medical equipment (DME) device requests; patient education (focus on Diabetes and Hypertension teaching); pre-visit planning; post- visit planning; pre-natal follow-up; medication administration; redirecting patients to appropriate services such as patient navigation and attend daily huddles.
  • Triage patients by conducting appropriate assessments within scope of practice in person and over the phone.
  • Ordering of patient medical equipment, emergency equipment, code cart & 02 tank upkeep, adherence to OSHA guidelines, availability of patient educational materials, etc.
  • Work as part of Care Teams to ensure that:
  • – Patients are screened and ready for Practitioner.
  • – Patients are treated and receive immunizations as ordered by the Practitioner.
  • – Patients are discharged with appropriate education and follow information.
  • Collaboration and Committee Involvement

  • Participate in Quality Improvement (QI) and Performance Improvement (PI) initiatives, including attendance at meetings, data input, and organization of project data and development of reports.
  • Provide guidance and counsel to staff in pre-visit planning and coordination of care with specialists and other providers, to include training of same as needed.
  • Other

  • Immediately report any problems or unusual occurrences to supervisor.
  • Other special projects/assignments as needed.

Minimum Experience and Skills Required:

  • Three years of experience in ambulatory setting ((emergency room, clinic or health center).
  • Must be knowledgeable about Patient Centered Medical Home guidelines and other regulatory
  • Demonstrated track record of organization, focus and ability to work in a fast-paced clinic.
  • Working experience with electronic medical records software.
  • Computer literacy in a Microsoft environment: MS Outlook, Word and Excel.

Education, Licenses and/or Certification Required:

  • Associate Degree in Nursing.
  • Valid Registered Nurse License in New York State.

Preferred Qualifications:

  • Bachelor of Science Degree in Nursing (BSN)
  • eClinicalWorks experience.
  • Bilingual: English/Spanish.

Competencies Required:

  • Customer Service
  • Professional, courteous and respectful attitude in dealing with patients.
  • Demonstrate the knowledge and skills necessary to provide care appropriate to the age of the
    patient served (if applicable).
  • Commits to exceeding expectations of the patient.
  • Cooperation/Teamwork
  • Works well with others.
  • Contributes input to improve outcomes.
  • Asks others for opinions and feedback, provides feedback in a tactful respectful way.

Minimal Training Time:
180 workdays orientation period.

Working Conditions:

Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is frequently required to sit, talk and hear.
The employee is occasionally required to move about the office; use hands and fingers to feel, handle, or operate office equipment.
Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work is primarily in a mental health clinic and general primary care setting which include the unpredictability in behaviors of individuals and acute and chronic infectious diseases which may be contagious. Adequate preparation and precaution is necessary.

The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position. This position may be required to perform other duties. If such work becomes a permanent and regular part of the job, a new description will be prepared.
Please forward resume and salary requirements to, and reference job title in the subject line.

Equal Opportunity Employer
Ryan Network is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, gender identity, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.