RN Case Manager

Job Description

Job Description

POSITION SUMMARY :

The RN Case Manager serves in an expanded healthcare role to collaborate with specialists, members of the healthcare team and patients / families to ensure the delivery of quality, efficient and cost effective healthcare services. Develops and assesses plan of care with patient / family, implements, monitors, and evaluates all options with the goal of optimizing patient’s health status. Utilizes evidence based clinical guidelines, preventive guidelines and protocols to develop patient centered care plans.

DUTIES AND RESPONSIBILITIES :

• Consults and communicates care objectives with primary care providers, specialists and community resources to aid patient in achieving healthcare goals.
• Identifies the targeted population by referral from primary care provider, patient registries.
• Assesses the healthcare, education and psychosocial needs of the patient / family.
• Identifies and maintains relationships with referral and community resources.
• Collaborates with primary care provider, patient, the healthcare team as well as community resources.
• Develops an individualized plan of care with targeted interventions, monitors patient and family’s response to plan of care and adjusts plan of care as needed.
• Provides patient with self-management tools / support to build ability for self-care.
• Maintains required documentation for all case management activities.
• Reviews current literature regarding engagement strategies, communication strategies and incorporates best practices into clinical setting.
• Maintain records and enter information into database as required.
• Assist team in defining and working to identified quality indicators, ie : HEDIS / UDS, North Star, PCI initiative, etc.
• Attends required in-service and departmental meetings.
• Follow up on hospital admissions and ED visits daily.
• Works with and manages our most complex patients to assure timely access to care and following treatment plan.
• Other duties as assigned

TYPICAL WORKING CONDITIONS :

TYPICAL PHYSICAL DEMANDS :

QUALIFICATIONS :

EDUCATION / EXPERIENCE / CERTIFICATIONS / LICENSES :

Family Health Center has the right to modify the duties and functions of the job description based on the needs of the organization.