RN Care Manager Resource

Job description

Scope of work: Plans and prioritizes care for individuals and population of patients, focusing on strategies that will promote optimal health within populations. Demonstrates expertise, current knowledge in nursing care and management of a caseload of patients of varying complexity and seeks to improve patient, family and health systems / community outcomes through the application of educational concepts / skills and preventive care in a managed care environment. - Assesses internal and external referrals to identify patient/significant others’ needs, level of intensity, insurance benefits and other patient resources. - Develops plan of care and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum. - Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals. - Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the conti...