Job Description
As an RN Case Manager you will be partnering with clinical teams to provide complex case management and strengthen the connection between the patient and the primary care physician / medical practice staff.
The Registered Nurse (RN) Case Manager is responsible for assisting patients to achieve their highest-level wellness. You will be Case Managing a specific patient population which includes complex medical conditions, social-economic and / or mental health co-morbidities.
The RN Case Manager will optimize the patient’s health status through assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services available to the patient.
The RN Case Manager will collaborate with approximately 5 patient care navigators and other members of a patient’s care team to achieve optimal quality, clinical, and financial outcomes.
This is a fully remote position supporting clients in the eastern time zone. We have a strong preference for candidates living in the Eastern or Central time zone.
WHAT YOU’LL BE DOING
Comprehensively assessing the healthcare and psychosocial needs of patients
Reviewing and amending patient navigator interviews with the patient.
Developing, implementing, and maintaining individualized care plans in accordance with all internal protocols and accreditation standards.
Providing evidence-based clinical interventions based upon the individualized care plan goals.
Partnering with patient navigator to manage non-clinical elements of care plan, such as making appointments, arranging transportation or food services, or other SDOH / non-medical patient needs.
Providing ongoing outreach to patients, continuously monitoring patient data and adjusting plan of care accordingly.
Developing with the PCP, patient specific escalation plans in the event of an acute, but non-emergent, exacerbation of key chronic conditions.
Providing education regarding conditions and treatment options.
Serving as an advocate for the patient and assist with accessing and engaging with services / resources that require clinical licensing, training, or knowledge.
Following up on service or resource referrals
Maintaining up to date documentation in the electronic medical health record as defined by protocol.
Utilizing evidence-based clinical protocols and guidelines along with defined quality metrics
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