Chronic Conditions RN - PCMH, DCSM Service Area *$10,000 Sign On Bonus
The Chronic Condition/Population Care Manager, RN, partners with members and adult primary care physicians and clinical nursing staff to achieve evidence based clinical objectives and goals specific to chronic conditions and preventive health measures. Responsible for facilitating quality care in accordance with standards of nursing practice, established clinical practice guidelines, and protocols.
* Provides multi-modal (e.g., telephonic, face to face, and video visits) adherence assessments, coaching and counseling for patients in the identified priority patient populations. Uses motivational interviewing techniques to identify patients readiness to change; implement appropriate actions based on assessment; support the member in developing a specific action plan when ready.
* Using evidence based developed protocols, coordinates with treating physician in adjusting treatment regimen to achieve clinical targets in identified-risk populations, e.g., heart failure, coronary artery disease, diabetes, hypertension, and asthma.
* Coordinates, and assists with planning, educational programs for members and their families, e.g. diabetic education, hypertension and cholesterol management.
* Participates in curriculum development and review for member education; assists in the curriculum delivery.
* Functions as part of a multidisciplinary team, including but not limited to: member, primary care physician, physician specialists, nurse, nurse practitioner, pharmacist, dietitian, social worker, and case manager, to develop, implement, manage, and evaluate the medical treatment plan and communicate with the providers.
* Identifies and discusses management of co-morbid conditions with member and treating physician to ensure excellent risk factor control.
* Reviews members current medical status and revises care plan as needed in conjunction with member, physician, and healthcare team.
* Provides ongoing member education and support.
* Assesses the medical regimen and members response, assists the member in developing specific care plans, and serves as the multidisciplinary team liaison for select member populations.
* Collect and maintain data base(s) to track member panel and improving member goals e.g. HEDIS and medical best practices.
* Uses appropriate applications (e.g. CarePoint) to access chronic populations needing outreach and care management.
* Performs other related duties as directed.
May have opportunities to work hybrid (in-person & remote)
Weekend and holiday rotation required
* Minimum three (3) years of adult primary care or family practice experience managing and educating individual populations with chronic disease is required.
* Associates Degree in Nursing.
License, Certification, Registration
* This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire.
* Registered Nurse License (Maryland) within 6 months of hire AND Registered Nurse License (Virginia) within 6 months of hire
* Compact License: Registered Nurse within 6 months of hire
* Registered Nurse License (District of Columbia) within 6 months of hire
* Experience with computer software programs in a Window environment required.
* Able to work independently required.
* Previous Experience with managing Congestive Heart Failure Patients.
* BSN Degree preferred.
* Knowledge of community systems and resources in the defined service area preferred.
* Knowledge of regulatory issues for the Mid-Atlantic area preferred.
Primary Location: Maryland,Rockville,Shady Grove Medical Center Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: 08:30 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: M38|UFCW|Local 400 Job Level: Individual Contributor Department: DCSM Service Area - Population Management - 1808 Pay Range: $43.67 - $48.93 Sign on bonus: $10000.00 Travel: Yes, 10 % of the Time At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
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