Care Management Nurse

Location: Hialeah

As Mount Sinai grows, so does our legacy in high-quality health care.

Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami-Dade (including our 674-bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not-for-profit hospital ,dedicated to continuing the training of the next generation of medical pioneers.

Culture of Caring: The Sinai Way

Our hardworking, tight-knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.

Position Responsibilities:

Responsible for the performance of Chronic Care Management and Transitional Care Management Programs. Achieve program’s standards:  Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week 
• Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments
• Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods (for example, email or secure electronic patient portal)
• Systematic assessment of the patient’s medical, functional, and psychosocial needs
• System-based approaches to ensure timely receipt of all recommended preventive care services
• Medication reconciliation with review of adherence and potential interactions
• Oversight of patient self-management of medications
• Coordinating care with home- and community-based clinical service providers
• Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge
• Timely create and exchange/transmit continuity of care document(s) with other practitioners and providers  Responsible for the performance of HEDIS Part D measures (medication adherence), and SPC and CBP, CDC, MRP measures from Part C Ensures patient is managed based on risk level of EPIC Registry Predictable Risk Model Identify patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate. Applies professional nursing skills in the provision of preventive health maintenance and/or treatment of illness. Assess learning needs of patient and significant other to support the patient through the care continuum.  Conducts pre-visit chart review of patients: Identification of all needed preventive health maintenance, immunizations and chronic disease interventions. Interventions may be ordered or completed before the patient sees a provider depending on standing order. Communicate the review to the IMED physicians.  Works independently to assess and evaluate understanding of disease process, treatment plan and/or lifestyle changes. Works with patients and families on self-management support: Setting short and long-term goals for self-management of chronic disease. Working with patient to create a plan for Health Behavior Change utilizing the 5A’s approach or similar process. Assessing and working on the patients’ readiness to change and the importance of change. Accurately and legibly documents all patient interactions in the patient record. Facilitates interdisciplinary communication and helping the patient to identify and overcome barriers. Provides or arranges needed patient education regarding specific health care skills and general disease concepts. Acts as liaison with patients and their families to physicians, in-patient and out-patient staff and other departments; and specialty clinics. Proactively acts as patient advocate, responding to and working to resolve patient concerns; providing a link to community resources. Documents programs specific outcomes. Involvement in QI activities: Assesses Satellites needs and then collaborates with leadership team on strategies to achieve individual clinic level goals such as quality and efficiency. Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report finding. Meets on a regular basis with other MSMC staff as coordinated by the Director of Medicare Clinical Operations for information sharing and continuing education activities and participates on committees as needed/requested. Typing of correspondence (memos and letters), statistical forms and procedures for patient reminder when overdue for screenings/tests to maintain complete patient records while keeping complete patient confidentiality. Other duties as assigned.

Qualifications:

RN Florida State Graduated from an accredited school of nursing. BSN preferred At least 6 months of experience as an RN. Experience in Chronic Care Management, Transitional Care Management and/or Care Coordination programs preferred. Experience in a Managed Care or ACO settings, a plus. 

Benefits:

We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs. Our robust employee benefits package includes:

Health benefits Life insurance Long-term disability coverage Healthcare spending accounts Retirement plan Paid time off Pet Insurance Tuition reimbursement Employee assistance program Wellness program On-site housing for selected positions and more! Share