RN Case Manager

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:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Must be able to work in stressful environment.
• This job operates in a professional office environment. This role uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
• While performing the duties of this Job, the employee is frequently exposed to airborne particles within a health care facility or home setting.
• The noise level in the work environment is usually quiet but occasionally may become disruptive while working with a client.

TYPICAL PHYSICAL DEMANDS:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel
• Must be able to communicate by talking or listening to hear conversational voices.
• The employee is frequently required to stand, climb stairs, walk and sit.
• Withstand frequent lifting, stretching and other physical exertion.
• Ability to manage exposure to patient elements: vascular access procedures, treatment of minor/major injuries, disposing of contaminated waste, cleaning and disinfecting equipment, handling of contaminated sharps.
• The employee is occasionally required to stoop and kneel.
• The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, peripheral vision and ability to adjust focus.

QUALIFICATIONS:

• Basic Life Support/CPR training
• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, interdisciplinary health care team, community agencies, patients/families with diverse opinions, values as well as religious and cultural beliefs.
• Demonstrates excellent written, verbal/listening skills.
• Demonstrates positive relationship building skills and critical analysis skills.
• Demonstrates ability to work autonomously and be accountable for practice.
• Demonstrates ability to influence to influence and negotiate individual and group decision.
• Demonstrates ability to function in a fluid, dynamic changing environment.

EDUCATION/EXPERIENCE/CERTIFICATIONS/LICENSES:

• Associate Degree in Nursing, required. Bachelor's Degree in Nursing, preferred.
• Minimum of one year experience with adult/peds medicine in primary care/ambulatory care, home health agency, skilled nursing facility or hospital medical-surgical setting within the past five years or an equivalent combination of education, and experience to perform the duties and responsibilities of the job.
• Licensed as an RN in the state of Michigan.
• Certification in Case Management preferred.

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