Nurse Care Manager, Virginia Medicaid, Falls Church MOB

Job Summary:

The nurse care manager is responsible for coordination of appropriate, cost-effective services that enhance a members quality of life, focus on a members optimal level of independence, and reduces inappropriate utilization of medical services. The nurse care manager collaborates with members and the health care team to achieve evidence based clinical objectives and goals specific to preventative health measures and improved disease self-management.

Essential Responsibilities:

• In close collaboration with the member/members family, and members of the health care team, assesses the members health status, functional limitations, psychological status, social support systems, resources, environmental factors, and response to treatment.
• Uses motivational interviewing techniques to identify members readiness for change, creates appropriate care plan based on assessments, assists member with health system navigation and connection to community resources.
• Provides supportive counseling and education to members, families and caregivers, members of the health care team, and others including end-of-life issues and Advance Directives.
• Effectively manages and coordinates assigned caseload consistent with established criteria. Ensures consistent and reliable documentation of case management activities in compliance with all organization and department standards.
• Facilitates application process for accessing local, state, and federally funded programs (e.g., Medicaid, Medicare, Disability) and/or refers to appropriate community-based resources.
• Provides education and coaching to improve overall self-management, health, and wellness.
• Monitors chronic health conditions to achieve optimal self-management.