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The Nurse Care Manager is responsible for coordinating and managing patient care to ensure continuity of care across multiple healthcare providers. The role involves working closely with patients, families, and interdisciplinary teams to assess, plan, implement, monitor, and evaluate care plans. This position aims to optimize patient health outcomes, reduce hospital readmissions, and improve overall quality of care.
Care Coordination:
Develop and implement individualized care plans for patients, ensuring all aspects of their healthcare needs are addressed.
Coordinate with physicians, specialists, social workers, and other healthcare providers to deliver seamless care.
Assist patients and their families in understanding their diagnosis, treatment plans, and available community resources.
Assessment & Evaluation:
Conduct comprehensive assessments of patients’ physical, psychological, and social needs.
Regularly monitor and update patient care plans based on changes in health status or care needs.
Identify and address gaps in patient care, including barriers to adherence and access to services.
Patient Advocacy:
Act as an advocate for patients to ensure their needs are met and that they receive the appropriate level of care.
Educate patients and their families about chronic disease management, treatment options, and self-care strategies.
Assist patients in navigating healthcare systems and accessing community resources and support services.
Quality Improvement & Compliance:
Monitor patient outcomes and report on care quality metrics to ensure compliance with clinical guidelines and organizational standards.
Participate in quality improvement initiatives and identify opportunities for enhancing patient care and reducing costs.
Maintain accurate and up-to-date patient records, documentation, and case notes.
Collaboration & Communication:
Collaborate with interdisciplinary teams to ensure continuity of care across different settings, such as hospitals, outpatient clinics, and home care.
Provide clear and timely communication to patients, families, and healthcare providers regarding patient status and care plans.
Participate in case conferences, team meetings, and continuing education sessions.
To apply for this job email your details to jessie.michaelson@windingwaters.org