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This position will work as needed

Job Title/Position: RN Care Manager



Job Classification: Direct/Indirect Patient Care



Date of Analysis: Date of Revision/Review:

__________________________________________________________________________________________



Brief Description of Job Responsibilities:

Responsible for coordinating the continuum of care for assigned patients and ensure optimum utilization of resources, excellent service delivery and positive quality outcomes, while minimizing unnecessary medical expenses.



Specialized Responsibilities:

(This list may not include all of the duties assigned)


* Implements evidence based treatment guidelines of clinically diagnosed condition.
* Prepare chart of assigned patients prior to appointment.
* Follow protocols for standing orders for medication refills, ordering tests and delivery of routine preventative services.
* Educate patients and families about managing their condition and or disease.
* Conduct previsit planning with providers.
* Write individual care plan with treatment goals.
* Assess patient barriers to unsuccessful outcomes as it relates to medication, appointments and goals.
* Coordinate visits with multiple clinicians and or diagnostic tests during one visit.
* Determine through triage how soon patients need to be seen.
* Provide telephonic advice on clinic issues.
* Identify health insurance or financial resources for patients.
* Systematically send or communicate medical information to patients.
* Review clinical measurements with patients at visits.
* Review information from facilities (discharge summary, hospital admission or ER visits) to determine if patients require a follow up visit or who are at risk for adverse outcomes.
* Contact patients after discharge from facilities.
* Provide or coordinate follow up care to patients/families who have been discharged.
* Develop written transiton plan in collaboration with family and patients when transitioning to another facility or provider.
* Aid in identifying a new primary care physician or specialist or consultant and offer ongoing consultation.



Performance Requirements:

Excellent communication, written and analytical skills.



Education/Experience/Certifications:


* RN with current Wisconsin license.
* Minimum of three years in clinic setting.
* Prefer specialty or primary care with EMR experience.
* Excellent assessment skills.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled