The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care. The incumbent in this role will first and foremost serve as an advocate for our patients. He/She works closely with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as, their home environments. The Nurse Case Manager 1 (RN) role also involves establishing relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. He/She adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.
Community Case Manager (primarily clinic and community based)
- Provides telephonic or outpatient visits to patients at high-risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, to disease management patients per the Disease Management Plan and to others as referred via transitional care team, acute case managers and Transitional Care team.
- Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
- Performs clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.
Coordinate the Plan of Care:
- Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
- Ensures individual plan of care reflects patient needs and services available.
- Makes recommendations to the team.
- Completes individual plan of care with patients and team members.
- Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
- Assesses the environment of care, e.g., safety and security.
- Assesses the caregiver capacity and willingness to provide care.
- Assesses patient and caregiver educational needs.
- Coordinates, reports, documents and follows-up on Super Huddles and HPP/IDT meetings.
- Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
- Coordinates the delivery of services to effectively address patient needs.
- Facilitates and coaches patients in using natural supports and mainstream community resources to address supportive needs.
- Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
- Establishes a supportive and motivational relationship with patients that support patient self-management
- Monitors the quality, frequency and appropriateness of HHA visits and other outpatient services.
- Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
Job Type: Full-time
Pay: $80,000.00 - $92,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible schedule
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Mileage reimbursement
- Paid time off
- Referral program
- Retirement plan
- Vision insurance
Schedule:
Education:
Experience:
- Nursing: 1 year (Preferred)
- Case management: 1 year (Preferred)
- Utilization review: 1 year (Required)
License/Certification:
Willingness to travel:
Work Location: Multiple locations