RN Case Manager

Responsibilities :

The Case Manager is responsible and accountable for ensuring high-value patient care via telephone and in the home that is coordinated, efficient, and aligned with clinical and financial objectives. In collaboration with the healthcare team, the Case Manager utilizes evidence-based practice to ensure that specific patient outcomes are achieved and that the resources are appropriately used within designated fiscal periods. With our members of the health care team, the Case Manager participates in the ongoing evaluation of practice patterns and supports efforts to improve patient care and enhance the efficiency of operations. The Case Manager identifies and works toward a resolution as a part of the multidisciplinary team. They provide services that reflect the mission, standards, and philosophy of the Hot Springs Health Program.

• Identifies the targeted high-risk population within practice site(s) per Provider referral, risk stratification, and patient lists. Includes patients with repeated social and / or health crises.
• Assesses over time the health care, educational, and psychosocial needs of the patient / family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborates with providers, patients, and members of the health care team, including a continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient / family response to the plan of care, and revises the care plan as indicated.
• Provides patient self-management support with a focus on empowering the patient / family to build capacity for self-care.
• Implements systems of care that facilitate close monitoring of high-risk patients and / or intervene early during acute exacerbations.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with the Provider, patient / family, community, and other members of the health care team. Fosters a team approach and includes patients / family as active members of the team. Takes the lead in ensuring the continuity of care, which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Provides follow-up with patient / family when the patient transitions from one setting to another. Completes timely post-hospital follow-up : Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teaching warning signs, review of discharge instructions, coordination of care, and problem-solving barriers.
• Demonstrate excellent written, verbal, and listening communication skills, positive relationship-building skills, and critical analysis skills.
• Maintains required documentation for all care management activities.
• Works with practice Providers and leadership to evaluate processes, identify problems, and propose / develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care model.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates them into clinical practice.

Qualifications :

Salary : $20 - $40