Nurse Care Manager - Telephonic

As a Nurse Care Manager with our Complex Care Management Team, you will use your strong organizational and planning skills to design and oversee the delivery of care plans for each patient on your panel. In this telephonic role, you will serve as the primary point of contact for your patients, creating meaningful relationships to maximize the likelihood of patient adherence to the established care plan. You will partner with all members of the Complex Care Management Team by gathering clinical input, facilitating team discussions, and coordinating all elements of the patients’ care plans. You will also be the central point-of-contact for your assigned PCPs, maintaining positive relationships between the PCPs and Tandigm Health. ESSENTIAL FUNCTIONS: Consistently exhibits behavior and communication skills that demonstrate Tandigm Health’s commitment to superior customer service, including quality, care, and concern for all internal and external customers. Serves as primary point of contact for patients and their PCPs. Performs initial case management assessments and determines their patients’ “current state” by evaluating their physical, psychological, social, environmental, financial, and functional status, as well as the strength of their support system. Develops multidisciplinary care plans that address key needs for each patient in their panel; the plans incorporate feedback and results from assessments conducted over the phone by the Nurse Care Manager or by other CCM members (e.g., Social Workers and Pharmacy Team). Coordinates key logistical activities and elements of each care plan, delegating to CCM members, as appropriate. Identifies and monitors the status of high-risk patients. Serves as the primary point of contact for patients’ medical needs; provides telephonic support, education, monitoring, and assistance to patients and caregivers. Consults regularly with Tandigm staff, Tandigm Medical Directors, and PCPs, as appropriate, to ensure that the care plan remains relevant, appropriate, and responsive to changes in patient status and/or goals. Maintains accurate and complete records, documenting pertinent patient information, patient and PCP communications, and all care management activity in the appropriate databases and within the parameters of care management policies and procedures. Maintains effective relationships with patients and families, PCPs and office staff, other providers, and community-based agencies. Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. Adheres to and responsible to abide by all information security policies, processes, and/or activities.