RN 2 - Care Management

17 Nov 2018
End of advertisement period
17 Jan 2019
Contract Type
Full Time

Work Days/Hours (Other than Standard)

Full-time, 37.5 hrs. Generally weekdays, 8:30 am - 5:00 pm. Early mornings, evenings, holidays and recess periods may also be required. Participates in weekend and holiday call rotation.

Position Focus:

In 1971, Yale University began a unique and historic experiment in providing health services to its faculty, staff, and students through a multidisciplinary health maintenance organization located on campus. Now, 47 years later, Yale Health has more than 37,000 members including students, staff, faculty, and their families who come from every state in the country and almost every country in the world.

The Care Manager is a member of the healthcare team and works collaboratively to enhance the delivery of patient care services along the continuum of care. Reporting to the Associate Director/Director of Nursing, the role will be responsible and accountable for high-value patient care that is coordinated, efficient and aligned with organizational clinical and financial objectives. In collaboration with the healthcare team, the CM utilizes evidence-based practice to ensure goals and outcomes are achieved and resources are appropriate utilized. The CM is expected to work toward interventions, resolutions and case management as part of an interdisciplinary team. Nursing responsibilities will include RN Transitional Care, Complex Care/Case Management, outreach, patient education and referrals management. Role will include outreach and management of specific targeted populations as identified.

Ideally, the Care Manager role connects patients and families to community health services, vendors, and resources as prescribed in a plan of care and as covered under the patients insurance benefit. Role may function in parallel, in lieu of or as a liaison to the primary care, nurse and PCP care team for those patients in need of intensive case management. Responsibilities include discharge planning, transition support, case management and collaboration with specialists, referral support and adherence to care plan. Role may collaborate with population health and other members of the Yale Health team around outreach to high risk and rising risk populations as indicated.

Essential Duties

  1. Performs physical assessments of patients, including triage duties and advises on treatment or course of action.
  2. Identifies and evaluates nursing services problems and develops and implements appropriate programs and services, including assessing staffing needs and arranging coverage as needed.
  3. Develops, implements, and manages nursing care plans in collaboration with physicians.
  4. Instructs patients and families in proper treatment and advises patients on health maintenance and disease prevention.
  5. Provides leadership, guidance, direction to clinical staff, and collaborates with nursing at all levels.
  6. Determines standards for quality assurance and infection control procedures; trains staff in universal and isolation precautions in the area of infection control.
  7. Performs diagnostic and therapeutic measures in collaboration with physicians.
  8. Evaluates the quality and effectiveness of nursing practice and nursing services.
  9. Records patients’ medical histories and symptoms, performs diagnostic tests and analyzes results, operates medical machinery, administers treatment and medications, and coordinates with patient follow-up and rehabilitation; assures all procedures for maintaining patient confidentiality are maintained per HIPAA guidelines.
  10. May perform other duties as assigned. 

Required Education and Experience 

Bachelor’s Degree in Nursing and two years’ experience or an equivalent combination of education and experience.

Required Skill/Ability 1:

Demonstrated ability to initiate, review, monitor and perform outreach to patients. Ability to serve as a Liaison to vendors (VNA, Home Care, STR, etc.), patients, family, PCP Care Team and Nursing Team. Ability to provide initial and comprehensive assessment to all patients referred and create individualized care plans that meet identified needs.

Required Skill/Ability 2:

Proven experience working with clinical care coordination or case management in an ambulatory facility or acute hospital setting. Proven experience in hospital-based nursing.

Required Skill/Ability 3:

Ability to facilitate and support specific populations that require complex care coordination or intensive case management. Ability to work with patients with chronic diseases and complex medical issues. Experience working with a variety of populations: students, pediatrics, adults, etc..

Required Skill/Ability 4:

Ability to use sound clinical judgment and decision-making in accordance with clinical practice guidelines and protocols. Excellent communication and interpersonal skills. Ability to interact positively and respectfully with a diverse population. Actively participates as a positive and effective team member.

Required Skill/Ability 5:

Computer proficiency related to the use of an EMR. Excellent attendance, punctuality and reliability.

Preferred Education, Experience and Skills:

2-3 years of clinical care coordination or case management experience in an ambulatory facility or acute hospital setting. 2-3 years of hospital-based nursing. Demonstrated experience in a med/surg unit or acute medical unit; experience in a large, high-volume multi-specialty group ambulatory practice; Home healthcare or relevant community health experience; proficiency in Epic.

Preferred Licenses or Certifications:


Background Check Requirements

All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. Please visit www.yale.edu/hronline/careers/screening/faqs.html for additional information on the background check requirements and process.

Posting Disclaimer

The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the particular position. Employees will be assigned specific job-related duties through their hiring departments.

Affirmative Action Statement:

Yale University considers applicants for employment without regard to, and does not discriminate on the basis of, an individual’s sex, race, color, religion, age, disability, status as a veteran, or national or ethnic origin; nor does Yale discriminate on the basis of sexual orientation or gender identity or expression. Title IX of the Education Amendments of 1972 protects people from sex discrimination in educational programs and activities at institutions that receive federal financial assistance. Questions regarding Title IX may be referred to the University’s Title IX Coordinator, at TitleIX@yale.edu, or to the U.S. Department of Education, Office for Civil Rights, 8th Floor, Five Post Office Square, Boston MA 02109-3921. Telephone: 617.289.0111, Fax: 617.289.0150, TDD: 800.877.8339, or Email: ocr.boston@ed.gov