Nurse Care Manager

Title:                Nurse Care Manager – ORPRN Research Focus

    Reports to:            Nursing Director

    Job Analysis:            October 2024

Note: Statements in this description are intended to reflect, in general, the duties and responsibilities of this classification and are not to be considered all-inclusive.

In the foundational Nurse Care Manager role the nurse will be 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.

This specific position includes, overlying foundational expectations, and taking precedent during the funded study period, project management (in Nurse Care Manager role) of ORPRN clinical studies.   The specific study funded this year (Project Year 1) is Co-Care.  See attached for study protocol and study-specific nurse duties. 

Key Responsibilities:

• Co-Care Research Study

  • Manage approximately 50 patient participants in the Collaborative Care for Polysubstance Use in Primary Care (Co-Care) study.

  • Review consented patient charts and prescription drug monitoring program (PDMP) for the presence of treatment agreements, urine drug screens, and risk factors.

  • Engage and assess patient participants: Conduct initial and ongoing evaluations for substance use disorder, physical and mental health symptoms, social supports, and barriers to treatment engagement and adherence.

  • Conduct urine drug testing, as indicated.

  • Educate and counsel patient participants: Provide health education on substance use and disease or symptom self-management.

  • Provide opioid risk reduction and overdose prevention counseling, and ensure that patient participants are offered naloxone kits and/or harm reduction kits and receive training in naloxone administration.

  • Support engagement in care: Outreach to patients in between scheduled primary care provider (PCP) visits or if a patient cancels/no shows to either PCP, nurse care manager, or mental health visits, to offer support and address barriers to care.

  • Refer patient participants to appropriate clinic and community resources, supporting ongoing engagement in primary care.

  • Meet with PCPs: Review patient participants, help interpret urine drug screen results, relay recommendations from addiction specialists and/or mental health counselors to PCP and patient.

  • Track prescriptions for patient participants and, when appropriate, prepare prescriptions for PCPs to sign.

  • Manage the clinical registry of information on all patients in the intervention, including entering all clinical and relevant information, reviewing data monthly with the addiction specialist, and prioritizing patients to be discussed, utilizing a standardized collaborative care model (AIMS model). 

• 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, counselors, addiction specialists 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.

Qualifications:

• Education:

  • Current Registered Nurse (RN) license in the state of Oregon.

  • Bachelor’s degree in Nursing (BSN) or higher preferred.

• Experience:

  • Minimum of 2-5 years of clinical nursing experience, preferably in case management, home health, or a care coordination role.

  • Experience working with diverse patient populations and chronic disease management.

  • Experience in project management desirable

  • Experience in team-based collaborative care desirable 

• Skills and Abilities:

  • Strong clinical assessment and critical-thinking skills.

  • Excellent communication, interpersonal, and problem-solving abilities.

  • Proficiency in electronic medical records (EMR) systems and care management software.

  • Ability to work independently and as part of a multidisciplinary team.

  • Strong organizational skills and attention to detail.

  • Commitment to providing compassionate, patient-centered care.

  • Commitment to serving underserved populations and working in a rural healthcare setting.

  • Ability to maintain the confidentiality of patient-related information such as protected health information (PHI), incident reports, research findings, and patient engagement efforts. Ability to maintain the confidentiality of business-sensitive information such as strategic, operational, financial, marketing, contracting, and grants metrics and plans.

Working Conditions:

• Work may be conducted in various settings, including hospitals, clinics, patient homes, or remote work environments.

• Travel may be required for home visits or meetings with patients and families.

• The role may involve periods of sitting or standing and occasional lifting of patient records or equipment.

Physical Characteristics

• Must possess the strength to work a minimum of 10-hour shifts.

• Must have mobility to move quickly about the Clinic.

• Must have the ability to lift 35 pounds.

• Must tolerate exposure to germs.

Clinic Culture:

• Know, understand, and practice Winding Waters Clinic's mission statement, policies, and procedures.

• Know, understand, and practice Oregon’s Patient-Centered Primary Care Home philosophy.

• Exhibit and foster a team approach and attitude.

• Promote and participate in the LEAN learning environment.

Application Process

Interested candidates should submit a cover letter, resume, and references to Human Resources Officer Jessie Michaelson at jessie.michaelson@windingwaters. org

Equal Opportunity Employer

Winding Waters Medical Clinic is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.