The RN- Care Manager is responsible for coordinating screening and developing interventions for patients identified as having complex chronic care needs. The RN acts as a connector between patient needs and the resources provided by the care management program. The RN assess patient health concerns and needs, develops and implements nursing care plans, and maintain patient records in accordance with Patient Centered Medical Home model of care.
As an organization devoted to service, Esperanza Health Centers has laid out statements of its Mission, Vision, and Values. All employees are expected to understand and live out these statements in their work lives.
To promote healthy lifestyles and improve our patients’ health through the provision of high quality health care and wellness services in the communities of Chicago’s southwest side.
eliminating barriers that restrict access to quality health care.
impacting the community by providing quality integrated primary care and behavioral health services.
building our communities by helping families with prevention and self-care education.
Principle Duties and Responsibilities:
1. Identifies, tracks and manages care for high-risk patients in collaboration with the entire care team. High-risk patients include individuals or families with co-morbidities such as diabetes, HTN, asthma and/or psychosocial issues.
2. Conducts initial care coordination screening eligibility and performs comprehensive risk assessment and medication reconciliation.
3. Oversees the development and implementation of an integrated patient care plan for each of the highest risk patients.
4. Responsible for achieving Care Management metrics including: transitions of care after admission, timely completion of care plans, decrease in hospital overutilization.
5. Responsible for the delivery of patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation.
6. Responsible for triage of patients who present for urgent care in the health center.
7. Assists with competency activities for Medical Assistants to ensure appropriate level of clinical skills and knowledge.
8. Contributes to the provision of quality nursing care through performance improvement techniques that demonstrate positive outcomes in patient care, with attention to population based measures.
9. Participates in center-wide training events and health related activities.
10. Participates in peer review chart audits.
11. Responsible for meeting the established standards of his/her profession and for practicing within the scope of licensure.
12. Performs all other duties as assigned.
13. Supports the organizational vision and mission.
JOB SPECIFICATIONS (Minimum Requirements)
1. EDUCATION: Bachelors of Science in Nursing (BSN) from a college or university
2. PREFERRED EXPERIENCE:
a. Two or more years working in a clinical setting.
b. Two or more years working with a Latino population.
3. Fluency in Spanish.
4. Ability to multi-task in fast paced environment.
5. Prior experience with electronic health records.
1. Graduate of an accredited School of Nursing.
2. Currently licensed or eligible for licensure in the State of Illinois.
3. Basic Life Support Certification, unless a doctor's release is provided, in which case, yearly proficiency must be demonstrated through oral and written testing.
4. Proficient oral and written communication skills.
1. Prior experience working in an outpatient setting.
Esperanza Health Centers serves an area that is in great need of quality healthcare. Families in Esperanza's service area experience significant economic, educational, and health disparities. More than 53 percent of residents live below twice the poverty level. Large portions of Esperanza's service area have been designated as a Medically Underserved Area and a Health Professional Shortage Area by... the Health Resources and Services Administration.
All of our full-time providers and all of our clinical staff are bilingual and bicultural. Our services and programs are carefully tailored to the needs and culture of the communities we serve.
Esperanza Health Centers is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
To promote healthy lifestyles & improve our patients’ health through the provision of high quality health care and wellness services in the communities of Chicago’s southwest side.
Esperanza means hope in Spanish. In living up to its name, Esperanza Health Centers envisions healthy communities where resources are woven together, allowing community residents to realize their full potential through optimum health regardless of immigration status, race/ethnicity, income or ability to obtain insurance.
HOPE: eliminating barriers that restrict access to quality health care.
HEALTH: impacting the community by providing quality integrated primary care and behavioral health services.
FAMILY: building our communities by helping families with prevention and self-care education.