Job Offer: Registered Nurse/Care Manager

Registered Nurse/Care Manager

Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and capability to pay, especially for the underserved and vulnerable. Hudson River HealthCare ('Sun River Health') is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full time Registered Nurse/Care Manager supporting the Hudson Valley Region.
The RN Care Manager is responsible for coordinating screenings, assessments, care planning, and providing care management services to patients identified as having complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. The RN care manager will promote self-care management and assist with access to care. The RN care manager works with patients through direct face to face patient contact or telephonically. Provides guidance and leadership abilities in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care.
Essential tasks and responsibilities of a Registered Nurse/Care Manager:

»Identifies, tracks and manages care for designated risk stratified patients

»Conducts initial care coordination screening eligibility and performs comprehensive risk assessment

»Works directly with patients/family members and providers to develop and implement an individualized and integrated patient care plan for patients

»Promotes clear communication amongst a care team including treating clinicians by ensuring consciousness regarding patient care plans

»Adapts practice to meet individual patient circumstances considering level of health literacy and cultural and linguistic differences, ensuring that effective communication is achieved, particularly where there may be barriers to knowledge

» continuing clinical assessment, monitoring and follow up for designated risk stratified patients

»Assessment and early identification of decompensating disease with appropriate intervention and management

»Assesses psychological needs and capability to benefit from community resources and referrals to outside agencies/programs when appropriate

»Hepatitis A, B, C screening

»Assist with family planning

»Performs medication review, reconciliation and coordination with a licensed prescriber for medication adjustment where indicated

»Provides organizational approved patient education materials including but not limited to health promotion and disease management

»Assists in the maintenance of the patient's health, wellness and avoidance of secondary disease complications by providing education, counseling and support

»Handles protective health information in a manner consistent with the Health Insurance Portcapability and Accountcapability Act (HIPAA)

»Collaborates with interdisciplinary teams to assess patient needs and deliver care to identified population upon discharge from varying clinical settings. Supports care transitions by coordination of activities needed to prevent or reduce utilization of emergency services or hospitalizations

»Ensures the continuing and timely reassessment and follow-up of all care plans on a scheduled basis ensuring timely updating and documentation of patient progress toward agreed upon goals

»Promotes the coordination of significant health and social care services to remove barriers related to social determinants of health
Required expertise and Qualifications required

»Registered Nurse (RN)

»Associate's degree in nursing required; Bachelor's degree preferred

» 1-2 years of practice working with patients and medical providers directly

»Documented proficiency in nursing tasks and achieving positive health results among patients
Hourly Range: $41.21 - $46.70/hour