Overview of the Role:
Privia is looking for an experienced, knowledgeable, curious, and driven Nurse Care Manager to partner with our Primary Care Providers in the Hampton Roads area. Our Nurse Care Manager will work directly in the office to collaborate with the providers to identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions and develop and maintain a systems based comprehensive care-plan. Our Nurse Care Managers seek to develop, implement, and deliver extensive care coordination within our medical group and affiliated partners in an efficient manner. They interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs.
- Build a trusting relationship with primary care providers and internal care center team members in an office setting 5 days a week
- Completing transition of care for a targeted patient population
- Manage a caseload of patients
- Develop trust and build rapport with a select Privia patient population
- Conduct assessments in designated time frame on patients identified as having two or more chronic conditions that put them at risk of death or functional decline (assessment areas include physical, mental, cognitive, psychosocial, functional, environmental, and financial state)
- Collaborate effectively with integrated care team to establish an individualized plan of care for patients
- Develop interventions to assist patients in meeting short and long term plan of care goals surrounding their chronic conditions
- Diabetes Management
- Congestive Heart Failure
- Pulmonary and Cardiac disease
- Engage patient, family, and caregivers to assure a well-coordinated treatment plan is established
- Prioritize care needs, set goals, and develop an initial plan of care to address gaps and/or barriers to care using evidence based guidelines
- Make efficient outbound calls to assess health status, identify care gaps or barriers in treatment plans
- Provide education to assist with self- management goals
- Make appropriate referrals to outside resources for collaborative care initiatives such as behavioral health.
- Educate patients on disease process or chronic condition
- Perform comprehensive assessments and documentation in a manner that is compliant Privia Care Management Playbook
- Understand and utilize the Athena and Privia Applications to determine high value opportunities and enter timely, accurate, and appropriate data
- BS in Nursing (or equivalent) and at least 3 years of case management or care coordination experience.
- Active unrestricted license in VA, DC, MD or able to obtain (if needed)
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.