At VillageMD, we are committed to helping patients achieve greater health by delivering the most effective, accessible and efficient healthcare in the world through partnership with primary care physicians. We're in a unique position to impact everyone in primary care from independent, family-owned practices to world-class health systems. As an extension of the primary care physician’s (PCP) care team, RN Care Managers are responsible for providing a variety of Care Management services within a PCP practice(s) targeting patients identified as high risk and/or those who are experiencing barriers to meeting their healthcare goals. Principle Care Management services include, but are not limited to, performing comprehensive assessments, developing patient-centered care pans, providing episodic and longitudinal care planning. RN Care managers also monitor acute facility stays and discharges, provide disease education and empower patient’s ability to develop self-management skills.
Integral to our Care Management team, the RN Care Manager will be accountable for supporting and improving the organization’s ongoing refinement of care management processes. As a new member of our team, you’ll work closely with our comprehensive care team to connect the dots of collaborative patient care while incorporating patients’ personal health and lifestyle goals.
What are some unique responsibilities that you’ll have at VillageMD?
- Actively engage and collaborate with PCP’s and office staff in identifying high-risk patients
- Employ motivational interviewing skills to elicit optimal member engagement/outcome
- Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers
- Communicate assessment findings, care plan goals, interventions and outcomes to PCP, patients and caregivers in a timely manner
- Monitor patient’s acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-discharge
- Identify and support practice needs for structured on-site Care Coordination presence in alignment with program model
- Maintain a core understanding of population management as it specifically relates to high risk patients
What will make you successful here?
- The ability to travel locally 4-5 days per week to different provider practices
- The ability to be flexible in an ambiguous and dynamic environment
- The ability to adapt quickly to changing demands in the healthcare industry
- A service orientation and a “can do” attitude
- A willingness to learn on your own and take initiative
- Displays Strength-Based Approach to collaborative problem solving
- The ability to receive feedback and apply it to work performance
- Demonstrates consistently, strong ethics and sound judgement
- Effectively engages diverse populations (age, ethnic groups, socio-economic levels, etc.) and provide culturally sensitive coaching, education and assistance to members and their families
- Experience in conflict management and problem resolution
- A low ego and humility; an ability to gain trust through good communication and doing what you say you will do
What you might do in your first year:
- Provide chronic disease education and symptom management teaching to patients and caregivers
- Assess medication adherence and perform comprehensive medication reconciliation
- Address Gaps in Care for High Risk patients engaged in Care Management services
- Document clinical interventions in applicable care management software systems
- Develop and maintain effective professional working relationships with assigned PCP practice(s)Engage patients in a variety of settings, determined by program models and initiatives