Nurse Case Manager (RN)

Position Summary:

• The RN Nurse Case Manager coordinates the care and service delivery of selected patient populations across the continuum of illness; promotes effective utilization and monitoring of health care resources; and guides all disciplines toward positive quality outcomes. They are responsible for the assessment of clinical and medical needs for each patient and serve as an advocate for the patient(s), caregivers and families to ensure their needs are met in a person-centered model of care.

Job Duties:

• Work closely with interdisciplinary care team manage care for high-risk, complex patient cases, including referral management, care planning, post-discharge planning and coordinating community-based and transitional care.
• Conduct individualized clinical evaluations of patients health needs; promote patient’s health and ensure that all personal health goals are included in person-centered care management plans.
• Identifies and manages other patient needs making referrals to the appropriate personnel; validate the need was addressed.
• Identifies patient educational, social and financial needs; referring to the appropriate personnel.
• Curate/approve (in collaboration with program supervisor) all educational materials for use with target populations served in this program with consideration of differences in cultural, generational and literacy needs across communities served.
• Provide health education to patients about preventing and managing chronic conditions using evidence-based sources.
• Develop personalized action plans, provide education, and issue referrals for care management programs; monitor patients’ progress in meeting established goals and modify care plans accordingly.
• Develop a cohesive and strong team-oriented relationship with physicians, nurses and other healthcare professionals.
• Evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care.
• Direct discharge planning process in support of treatment adherence and medication compliance; assist with transitions for patients discharged from an in-patient hospital to a skilled nursing facility.
• Guide, intervene and advocate on behalf of patients, their caregivers and/or families in regard to navigating and comprehending the healthcare system; coordinate resources in the community to ease transition.
• Advocates on behalf of patients and caregivers for identification and access to services. Advocates for the protection of the patient’s health, safety and rights. Ensure patient choice and consistently support a patient centered environment.
• Perform other job-related duties as assigned.

Required Skills/Abilities:

• Excellent verbal and written communication skills.
• Excellent interpersonal, negotiation, and conflict resolution skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Ability to prioritize tasks and to delegate them when appropriate.
• Ability to act with integrity, professionalism, and confidentiality.
• Proficient with Microsoft Office Suite or related software.
• Participate in the organization’s Performance & Quality Improvement (PQI) activities assigned by supervisor.
• Regular and predictable attendance, and promptness for work.
• Commitment to uphold the mission, vision, and values of Lutheran Family Services.
• Support Lutheran Family Services in the organization’s objective to be a diverse, equitable, inclusive, and accessible workplace.

Position Competencies:

• Verbal Communication
• Written Communication
• Critical Thinking
• Organizational Skills

Education and Experience:

• Successful completion of a state approved nursing program.
• Active and unrestricted RN license.
• Minimum of two years clinical experience.
• Strong knowledge of clinical assessment skills and experience with chronic disease management.
• Clinical experience in case management preferred.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Hybrid work environment (in office, in community, and remote).
• Company-issued laptop and cell phone.
• Travel to various office locations to meet client needs, as needed / as applicable by region.
• Work a flexible schedule, including evenings and weekends to meet client needs (as directed).

Lutheran Family Services is an equal opportunity employer. We do not discriminate against any employee or applicant for employment on the basis of age, race, religion, color, ethnicity, disability, gender, sexual orientation, gender identity, or national origin

Job Type: Full-time

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Retirement plan
• Vision insurance

Schedule:

• Day shift

Work Location: In person