Anti-coagulation, RN Case Manager (Regular and Temp Shifts)
Apply NowCompany: Codman Square Health Center
Location: Dorchester, MA 02125
Description:
Position Summary:
Complex Care Nurse Manager with a concentration in Anti coagulation Management (AC) Case Manager will report the Manager of ACO and Care Management. The Anti-coagulation Nurse Case Manager will work collaboratively with Primary Care Providers (PCP) in all Clinical areas to manage patients on anti-coagulation therapy, reviewing treatment plans, adjusting medication doses according to AC guidelines/standards and ensuring patient adherence. The goal is to minimize risks associated with AC therapy through education, monitoring, and communication
Primary Responsibilities:
Care Management
Manages all aspects of developing, implementing, and evaluating individualized patient care plans for patients on anti-coagulation therapy
Educates patients, families, and healthcare providers on how to follow and maintain the care plans.
Collaborates with Primary Care Providers, Clinical Pharmacist, Staff nurses, Community Health Workers, Patient Navigators, and outside agencies ( outside labs, visiting nurses, and hospitals).
Maintains and manages Anti-coagulation registry
Manages Anti-coagulation Internal Referral list
Educates patients, families, and healthcare providers.
Participates in Health Center Case Management meetings
Direct Patient Care
Competent with all aspects noted in the job description for a registered nurse.
Coordinates and manages scheduled nurse visits, and co-manages care with a clinical provider.
Conducts comprehensive assessments of patients' physical, mental, and psycho-social needs including initial histories and assessments for new AC patients.
Provide point of care testing for new and existing AC patients.
Provide lab ordering for new and existing AC patients.
Provide clinical support and liaison services for AC patients being seen at outside agencies.
Develops and manages individualized care plans; including managing all preventative care, administration of vaccines and treatments, testing and evaluation of plan's effectiveness.
Assess and monitor patient's medication for compliance and side effects.
Maintain data to monitor clinical outcomes.
Assist patients in navigating the health care system. Coordinates specialty care, follow-up on test results and other care coordination needs to patients and providers.
Develop a care plan to promote patient engagement in self-care, decrease risk status, and minimize hospital and emergency room utilization.
Utilize behavioral strategies to help patients adopt healthy behaviors and improve self-care.
Promote self-management goals.
Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of ED visit notification.
Ongoing evaluation and documentation of patient progress/risk status;
Document accurate clinical and billing information in the electronic medical record.
Provide service that maintains high customer service levels.
All other duties as assigned.
Qualifications:
Registered Nurse licensed in Commonwealth of Massachusetts (BSN required).
CCM Certification preferred
CACP Certification preferred
Experience in Anti-coagulation management required.
Detail oriented, collaborative and able to work independently.
Demonstrate excellent communication (written and verbal, in person and on the phone)
Sensitivity to ethnic, cultural, gender; beliefs, and behaviors.
Multi-lingual is preferred.
Experience working with target populations.
CPR/BLS certified
Codman serves a diverse population. Applicants who have a multicultural background and/or bilingual are encouraged to apply. We offer a generous benefits package including:
A retirement employee-funded 403(b) plan
Competitive Medical, and Dental
Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance
Generous Vacation, Holiday, Personal and Sick Time Benefits
Flexible Spending Reimbursement Accounts (Health and Dependent Care)
Educational Assistance and tuition reimbursement Programs
Commuter Benefits
Other benefits and perks!
Codman Square Health Center is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.
Complex Care Nurse Manager with a concentration in Anti coagulation Management (AC) Case Manager will report the Manager of ACO and Care Management. The Anti-coagulation Nurse Case Manager will work collaboratively with Primary Care Providers (PCP) in all Clinical areas to manage patients on anti-coagulation therapy, reviewing treatment plans, adjusting medication doses according to AC guidelines/standards and ensuring patient adherence. The goal is to minimize risks associated with AC therapy through education, monitoring, and communication
Primary Responsibilities:
Care Management
Manages all aspects of developing, implementing, and evaluating individualized patient care plans for patients on anti-coagulation therapy
Educates patients, families, and healthcare providers on how to follow and maintain the care plans.
Collaborates with Primary Care Providers, Clinical Pharmacist, Staff nurses, Community Health Workers, Patient Navigators, and outside agencies ( outside labs, visiting nurses, and hospitals).
Maintains and manages Anti-coagulation registry
Manages Anti-coagulation Internal Referral list
Educates patients, families, and healthcare providers.
Participates in Health Center Case Management meetings
Direct Patient Care
Competent with all aspects noted in the job description for a registered nurse.
Coordinates and manages scheduled nurse visits, and co-manages care with a clinical provider.
Conducts comprehensive assessments of patients' physical, mental, and psycho-social needs including initial histories and assessments for new AC patients.
Provide point of care testing for new and existing AC patients.
Provide lab ordering for new and existing AC patients.
Provide clinical support and liaison services for AC patients being seen at outside agencies.
Develops and manages individualized care plans; including managing all preventative care, administration of vaccines and treatments, testing and evaluation of plan's effectiveness.
Assess and monitor patient's medication for compliance and side effects.
Maintain data to monitor clinical outcomes.
Assist patients in navigating the health care system. Coordinates specialty care, follow-up on test results and other care coordination needs to patients and providers.
Develop a care plan to promote patient engagement in self-care, decrease risk status, and minimize hospital and emergency room utilization.
Utilize behavioral strategies to help patients adopt healthy behaviors and improve self-care.
Promote self-management goals.
Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of ED visit notification.
Ongoing evaluation and documentation of patient progress/risk status;
Document accurate clinical and billing information in the electronic medical record.
Provide service that maintains high customer service levels.
All other duties as assigned.
Qualifications:
Registered Nurse licensed in Commonwealth of Massachusetts (BSN required).
CCM Certification preferred
CACP Certification preferred
Experience in Anti-coagulation management required.
Detail oriented, collaborative and able to work independently.
Demonstrate excellent communication (written and verbal, in person and on the phone)
Sensitivity to ethnic, cultural, gender; beliefs, and behaviors.
Multi-lingual is preferred.
Experience working with target populations.
CPR/BLS certified
Codman serves a diverse population. Applicants who have a multicultural background and/or bilingual are encouraged to apply. We offer a generous benefits package including:
A retirement employee-funded 403(b) plan
Competitive Medical, and Dental
Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance
Generous Vacation, Holiday, Personal and Sick Time Benefits
Flexible Spending Reimbursement Accounts (Health and Dependent Care)
Educational Assistance and tuition reimbursement Programs
Commuter Benefits
Other benefits and perks!
Codman Square Health Center is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.