RN Case Manager - Primary Care Plus - Westwego, LA (885992)
About the Job
Position Description As Senior Care Specialists, we understand the needs of our patients. Primary Care Plus doctors, nurses and staff know how to treat the health challenges that arise with aging. Because we focus on seniors, our doctors see about half of the patients of a typical primary care doctor. This allows more time at every appointment to get to know the patient, to understand individual health goals and to provide effective and highly personalized health care at every opportunity. Primary Care Plus is dedicated to patient health through continuity of care. As a new member of the UnitedHealth Group family of companies, Primary Care Plus is expanding its impact and sense of contribution. Join us and start doing your life's best work.(sm)As part of the patient centered medical home team, the RN Care Manager engages in a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a patient’s health needs. The RN Care Manager will facilitate the coordination of care resulting in more efficient utilization of health care resources, decreased hospital readmissions and improved health outcomes.Primary Responsibilities:Works with facility and health plan representatives to coordinate the discharge planning process and transition needs based on patient’s diagnoses and statusCollaboration with the clinic team to proactively manage high risk patients by ensuring appropriate:-Frequency of PCP visits, Specialist referrals, Testing/screenings-Medication Management to include medication reconciliation post discharge and medication adherence-Chronic disease educationProviding self-management support to patients in order to improve their health outcomesLeads daily/weekly/monthly discussions where patients’ goals, outcomes, interventions, and recommendations for improvement are discussed with members of the patient’s care teamVisit members in their homes or hospitals settings as neededYou’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.