What are the responsibilities and job description for the RN Case Manager position at Tampa Family Health Centers?
Job Description
Job Description
Position Summary
The RN Case Manager has the overall responsibility for providing and coordinating screening and interventions for patients identified with chronic and complex care needs. Works collaboratively, as part of the care team, to implement evidence-based series, protocols, and methods for primary care patients.
Essential Duties & Functions
- Conduct telephonic contact with patients identified with chronic and complex care needs
- Ensure systematic use of an initial Health Risk Assessment (HRA) for patients deemed eligible for care coordination
- Conduct in-person visits if needed, to detect level of care coordination / management needs
- Work with patients in the creation of a care plan, or in review and update if there is an existing care plan.
- Use a variety of education materials, brief intervention techniques, and community resources to engage patients, increase their motivation to change, and support patients in establishing behavior change goals and implementing plans to meet those goals
- Establish a follow-up schedule and monitor patients’ progress, using an electronic care management tracking system
- Maintain accurate and up-to-date records and standardize data on all patients
- Clearly and effectively communicate with the patient, PCP, and any external providers, information from the PCP about the patient’s progress; discussing side effects and care plan with the PCP and other care team members, as needed
- Develop a maintenance plan with patients, when appropriate, to help them maintain a healthy lifestyle and prevent a reoccurrence of symptoms of their chronic condition(s)
Required Education, Certifications, Licenses, & Training
Required Years of Experience
Required Knowledge, Skills, and / or Abilities
