Outreach Nurse Case Manager

Job Type

Full-time

Description

The Outreach Nurse Case Manager will be responsible for helping patients and their families to navigate and access community services, other resources, and adopt healthy behaviors.

The Outreach Nurse Case Manager supports providers and the support staff through an integrated approach to care management and community outreach.

As a priority, activities will promote, maintain, and improve the health of patients and their family. The Outreach Nurse Case Manager will provide social support and informal counseling, advocate for individuals and community health needs, and provide services within scope of practice.

Community outreach, such as home visits and health screenings will be required.

1. Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.

2. Provide ongoing follow-up, basic motivational interviewing and goal setting with patients / families.

3. Follow-up with patients via phone calls, home visits and visits to other settings where patients can be found.

4. Help patients set personal health related goals and attend appointments.

5. Provide referrals for services to community agencies, as appropriate.

6. Help patients connect with transportation resources and give appointment reminders in special circumstances. Transporting patients is strictly prohibited.

7. Exhibit excellent working relations with patients, visitors and staff, effectively communicating Bluestem's Health mission.

8. Work closely with medical provider to help ensure that patients have comprehensive and coordinated care.

9. Work cooperatively with other clinical personnel assigned to the same patient.

10. Be knowledgeable about community resources appropriate to needs of patients / families.

11. Be responsible for providing consistent communication to the care team to evaluate patient / family status, ensuring that provided information, and reports clearly describe progress

12. Act as a patient advocate and liaison between the patient / family and community service agencies (i.e. schools, DHHS, hospitals, support groups, etc.).

13. Record patient care management information in the EMR and other software no later than 48 hours after patient contact.

14. Attend regular staff meetings, trainings and other meetings, as requested.

15. Manage assigned caseload of patients.

16. Maintain HIPAA compliance at all times.

17. Responsible for developing plan of care, service coordination and linkage to key community services.

18. Other duties as assigned.

Requirements

• High School Diploma or its equivalent, required.
• Registered Nurse or LPN, preferred.
• Background in motivational interviewing / health coaching preferred.
• Written and oral fluency in Spanish and English is preferred.
• Experience working in a multi-cultural setting.
• Experience working in a community-based setting for at least 1 to 2 years preferred.
• Knowledge of some medical terminology preferred.
• Basic computer skills required, electronic medical record (EMR) experience preferred.
• Ability to initiate and maintain positive working relationships with Bluestem Health staff and other organizations.
• Understand the community served, community connectedness.
• Good communication skills, such as listening well, and using language appropriately.
• Ability and willingness to provide emotional support, encouragement and motivation to patients
6 days ago