The Department of Family Medicine at Macon & Joan Brock Virginia Health Sciences at Old Dominion University is seeking an RN, Care Manager to join the team.

Provides prescribed medical treatment and personal care services to ill, injured, convalescent and disabled persons in such settings as hospitals and/or doctor’s office. As a key clinical staff member within the Department of Family Medicine, this position will lead the team members who are providing care coordination services to include Medicare Wellness Visits, Care Management of Chronic Diseases, and Transitional Care Management. This position will also assist with Departmental ACO Quality Measures, Resident education and Quality Projects. Mentor other clinical staff such as Medical Assistants and LPN’s. Will be responsible for direct supervision and training of LPNs.

• Work with the Chief Quality Officer to improve clinical quality metrics and outcomes in the department and organize/provide leadership towards ensuring that the department meets ACO Quality Measures. Identifying areas of opportunity and providing recommendations for workflow optimization within the care management team.
• Supervise LPNs including managing performance, approving timecards, and issuing corrective action when needed
• Schedule and conduct Medicare Wellness visits in compliance with current CMS guidelines. Complete patient assessments over the phone during TOC calls, following discharge from any inpatient facility and ensure any status changes or patient needs are communicated with the appropriate provider. Conduct chart audits of Medicare Wellness visit notes and TOC notes completed by LPNs to ensure all criteria for appropriate billing have been met. Communicate changes to CMS guidelines with care managers and billers.

• Assist with specialty clinics (as needed): (this isn’t something I’ve ever done and could be removed but maybe was included as a catch all if it ever became necessary)

• Coumadin Clinic-Check patient’s INR and adjust Coumadin dose as needed. Review and teach diet restrictions. Document results and bill for procedures. Talk to home health nurse re: INR results and adjust doses.

• Colposcopy Clinic-set up and assist with procedures. Assist physicians with Colposcopy procedures. Process and send specimens to pathology (Sentara or Labcorp). Record in Procedures notebook, follow up for results, physician’s verification and patient notification. Call no show patients and reschedule.

• Minor surgery clinic-set up clinic and assist with procedures. Process and send specimens.

• (Dermatology, Labcorp) Follow results for physician verification and patient notification.

• Flexible Sigmoidoscopy-done during minor surgery. Assist physician. Call patients prior to and after appointment to review prep and answer questions.

• Treadmill Clinic-prepare patients for testing. Assist with test. Monitor vital signs. Call patient prior to testing, verify appointment, review instructions and answer questions.

• Complete all in basket requests assigned to individual team (as well as covering for other nurses who may be temporarily absent), including responding to patient messages, prescription refills, lab results, referrals, home health agencies, medication prior authorizations, patient forms and follow up from physicians. All tasks must be reviewed, addressed and marked appropriately before the close of each business day. Respond to questions from patients, family members, faculty/residents, other health care providers in a timely and professional manner. Patient phone calls should be answered on the same day they are logged in, before leaving for the day. If patient is not home at the first attempt, a notation should be made in the medical record. All patient conversations must be documented in the electronic medical record. Takes and records patients’ vital signs
• Administers specified medication, orally or by subcutaneous or intermuscular injection, and notes time and amount on patients’ charts. Assembles and uses such equipment as catheters, tracheotomy tubes, and oxygen supplies. Collects samples, such as urine, blood and sputum, from patients for testing and performs routine laboratory test on samples.

Minimum Qualifications and Skills:

• RN diploma.
• Must be a licensed RN in Virginia.
• Completion of BLS class and re-certify every two (2) years.
• Ability to make professional nursing decisions up to the scope of practice for licensure and possess the knowledge and critical thinking skills to support those decisions.
• Possess complex patient management skills.
• Possess assessment and medical decision making skills and develop a care plan for the wellness visit.
• Possess professional interaction skills with physicians, patients, outside offices, pharmacies, referring agencies, hospital personnel and support staff.
• Ability to lead and manage teams.
• Ability to coordinate and track Clinical QI Projects.
• Ability to work with senior leadership.