Join Privia - Population Health Technology | Privia Health
Nurse Care Manager
Clinical Operations
Virginia Beach, VA
Full Time

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Privia is looking for an experienced, knowledgeable, curious, and driven Embedded Nurse Care Manager to partner with our Primary Care Providers in the Hampton Roads area. Our Embedded 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. 
 

Primary Responsibilities:

  • Build a trusting relationship with primary care providers and internal care center team members in an office setting 5 days a week
  • Assist and Complete 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 and remote patient monitoring
  • 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

Minimum Qualifications:

  • 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)

Interpersonal Skills & Attributes

  • Strong organizational skills and multitasking abilities
  • Ability to solve complex problems; critical thinking skills; emotional and social intelligence
  • Strong verbal communication skills
  • Strong motivational interviewing skills
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
  • Maintain a positive caring attitude towards patients and team members
  • Proficient with Microsoft Office applications including Word, Excel, and PowerPoint
  • Independent problem identification/resolution and decision making skills
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
  • Ability to function efficiently in a virtual environment and meet defined goals

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