Disease Management Nurse
Sinai has an exciting opportunity for two Full Time Diease Management Nurses. Disease management encompasses the clinical, economical and psychosocial aspects of providing health care and entails a certain amount of proactive, preventative services. Disease management seeks to influence or encourage the modification of the health-related behaviors of patients, providers and purchasers to reduce the occurrence and severity of certain disease states or conditions. The Disease Management Nurse:
- Provides a comprehensive assessment of patient risk and needs for education, discharge planning and resource needs during an episode of illness and across the continuum of care
- Directs the patient throughout the system by coordinating care with the PCP, physician, direct care staff, interdisciplinary team which includes the patient and family; arranges for a PCP for patients who do not have an existing relationship
- Streamlines transitions in and out of the hospital, speeds up referrals and ensures prompt scheduling of follow-up appointments taking in to consideration patient preference and schedule; reinforces discharge plan and compliance
- Working with the interdisciplinary team, develops and implements disease specific protocols and order sets for the entire continuum of care based upon the latest evidence based recommendations; Collects data on the utilization and effectiveness of these tools and recommends changes as necessary and as the evidence changes.
- Develops effective working relationships with PCPs, Specialists, care team members, home health agencies, SHS administrative leadership, medical leaders, SCI and SUHI program staff, clinic networks, and other support organizations
- Assures that an appropriate plan of care is created and documented for the patient; ensure that the plan of care is appropriately communicated and understood by the health care delivery team.
- Assess and document patient’s readiness to change and self-management abilities; provides teaching to the patient that provides them with information that is comprehensive and culturally appropriate; employs advanced teach-back methods.
- Coordinates the creation of the After Hospital Discharge Plan; reviews with the patient for input and instruction; assure patient understanding of who to contact when there is a problem; how to identify red flags, key self-management skills; assures delivery to the PCP
- Contacts patients post discharge/ office/clinic visit to assess continued knowledge of disease, answers questions and assure that planned care and services are completed; refers patients for additional services as need is identified
- Participates in the development and presentation of disease management quality improvement reports for presentation to various committees and groups internally and externally.
- Maintains appropriate documentation on activities/discussions with patients in the approved disease management record/system.
- Develops and maintains excellent working knowledge of disease management/care management/healthcoaching skills and systems; stays abreast of current/upcoming enhancements to this field of knowledge; maintains excellent knowledge of disease state assigned
Schedule is typically Monday - Fridays, Days unless otherwise needed
- Bachelor’s Degree in Nursing field; Master’s Degree strongly preferred.
MINIMUM WORK EXPERIENCE:
- Minimum five 3-5 years experience in a related clinical nursing position. Prior experience in disease management/care management/health coaching highly desirable.
KNOWLEDGE & SKILLS:
- Demonstrated knowledge and experience in management of disease processes
- Demonstrated knowledge of disease management/care management/health coach processes
- Demonstrated ability to develop and employ effective patient teach back methods
- Demonstrated knowledge of facilitating and coordinating patient care plans
- Excellent oral, written, and interpersonal communication skills. Ability to work independently and also as a team with a wide variety of individuals; Excellent organizational skills
- High degree of creativity in problem-solving; ability and patience to navigate and impact complex systems of care.
- Proficient computer skills
- Willingness to work some weekends
REQUIRED LICENSES, Certificates, Registrations:
- Registered Nurse with current Illinois license required; Disease management certification desired