Nurse Care Manager Contract

Sunset Health - Yuma, AZ

Yuma, AZ

About the position

The position functions as a liaison for patients, caregivers, and families, helping them navigate the continuum of care and serving as a patient advocate in inter-disciplinary meetings. The role involves collaboration with a patient-centered medical home inter-disciplinary team, including providers, pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nursing support personnel to achieve optimal patient outcomes. The individual will interact with patients, caregivers, provider teams, and the community to ensure continuity of care, coordination of services, timely follow-up, and effective care planning. Responsibilities include identifying early risk factors, conducting ongoing health assessments, and maintaining accurate care records within the electronic health record system. The position also requires collaboration with health plans and hospitals to identify patients who have had recent hospitalizations or emergency department visits, and to facilitate follow-up care. Additionally, the role involves proactively addressing barriers to care, providing support services, and ensuring quality of care by adhering to evidence-based guidelines.

Responsibilities

• Act as a liaison for patient/caregiver/family in navigating the continuum of care.
• Collaborate with the patient-centered medical home inter-disciplinary team.
• Interact with patients, caregivers, provider teams, and the community.
• Identify early risk factors and conduct ongoing health assessments.
• Maintain accurate care records within the electronic health record.
• Collaborate with health plans and hospitals to identify patients needing follow-up.
• Proactively identify and address barriers to care.
• Provide support services and referrals as recommended by inter-disciplinary teams.
• Assure quality of care by adhering to evidence-based guidelines.
• Participate in the Quality Program and Compliance Program.
• Participate in the Infection Control Program.

Requirements

• Familiarity with principles of care management and preventive care guidelines.
• Ability to prioritize a case load and interact professionally with healthcare professionals.
• Knowledge of physical and behavioral health medications.
• Ability to organize effectively and efficiently.
• Bilingual in English/Spanish preferred.
• Must obtain fingerprint clearance and pass a background check.

Nice-to-haves

• Experience in community liaison with support agencies and non-profits.
• Knowledge of computer and general office skills.
• Experience in a primary care ambulatory setting.

Benefits

• Reasonable accommodations for individuals with disabilities.