Position Summary:
The Disease Management Community Based Registered Nurse (CBRN) provides disease management nursing services and care coordination to high risk, high cost Medicaid patients in a geographical region. The RN provides education, counseling and on-demand information to Medicaid beneficiaries who have enrolled in a condition specific program. As needed, the CBRN will provide program education and coordinate care needs with the patient’s Primary Care Provider. Services are performed in person or telephonically and interventions are recorded in the Population Care Management (PCM) application.
Key Responsibilities (List five to seven essential responsibilities in priority order):
1. Delivers DM program content in accordance with established standards and creates a patient specific plan of care using the nursing process. Establishes long and short term goals in collaboration with the client.
2. Maintains a caseload of high risk-high cost members in accordance with policy, performing both face to face and telephonic interventions with Medicaid clients.
3. Coordinates care required to reduce client self care management barriers to include assisting patients with program home monitoring devices.
4. Collaborates with providers of care to ensure appropriate access to services and follow up on the results of referrals.
5. Works collaboratively with support personnel to maintain efficiency in scheduling of patient visits.
6. Maintains timely, accurate required records and reports.
7. Follows complaint and grievance policy.
Education/Training – Registered Nurse licensed by the State of with an Associates Degree in Nursing, Bachelor of Science in Nursing preferred. Certification or experience in case management or home health preferred.
Experience – Minimum of 3 years recent clinical experience preferably managing patients with the chronic conditions of asthma, diabetes, heart failure, COPD, CAD.
Specialized Knowledge/Skills –
- Windows environment (preferably Word and Excel)
- Excellent written and verbal communication skills
- Excellent organizational skills
- Current CPR certification
- Current PPD
- Current valid driver’s license and required level of automobile liability insurance coverage
