Registered Nurse - Patient Aligned Care Team

Summary The Registered Nurse Care Manager (RNCM) is responsible for organizing and directing team members to achieve desirable patient outcomes through day-to-day and/ or telephonic case management. The RNCM functions in the Primary Care Clinic which utilizes a Patient Aligned Care Team (PACT) model. The RNCM uses the nursing process and evidence-based practice to collaborate with the Core Team in developing the patient-driven care plan. Responsibilities Duties include, but are not limited to: Demonstrates clinical knowledge in assessing, planning, implementing documenting and evaluating care for a designated group of patients across the continuum of care. Triage and apply a collaborative team approach in identifying, analyzing and resolving patient care problems. Collaborates with patients to assess and identify needs, issues, care goals and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness. Maintains cur...