The Case Manager is a Registered Professional Nurse or Licensed Practical Nurse who has clinical experience with medically complex patients. The nurse is responsible and accountable for direct and indirect patient care across the care continuum, with a primary focus being on patients with chronic care needs and with multiple co-morbidities. This position requires expertise in the nursing process and critical thinking skills to plan and coordinate care. Works in coordination with the referral coordinator, multiple PCPs and Director of Quality. The Case Manager monitors patient progress and coordinates clinic and community resources to assist patients in reaching disease prevention targets. Assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes. The work includes responsibility for significant interpersonal staff and public contact, appropriate and professional conduct, professional attire, independent judgment, discretion, and personal initiative as well as the resolution of difficult and complex problems. Excellent communication skills and the ability to consistently maintain composure throughout all situations is an absolute must for this position.
Specific Duties and Responsibilities: Patient Relations
- Serve as system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns. May assume advocate role on the patient’s behalf to ensure approval of the necessary supplies/services for the patient in a timely fashion.
- Ensure that the patient’s primary care chart is up to date with information on specialist consults, hospitalizations, ER visits and community organization related to their health.
- Performs patient teaching, patient self-management/self-efficacy coaching and planned care management. Ensures coordination for specialty and other handoffs as necessary.
- Serves as a liaison between patient, PCP, insurance companies and specialty providers
- Assist patients in accessing their health care benefits, i.e. transportation, interpretation services, etc.
- Ensure patient confidentiality.
- Routinely provide patients with other clinic and community-based resource materials as appropriate.
- Other duties as assigned
Certification of practice as a Registered Nurse, or a Licensed Practical Nurse with previous case management experience.
- Bilingual skills preferred but not required.
- Must be qualified in Basic Life Support techniques.
- Must have a working knowledge of Microsoft office products, and familiarity with network systems.
- Ability to understand and present verbal instructions and to exchange verbal information is essential.
- Excellent organizational, written and customer service skills necessary.
- Ability to travel to all locations and to meetings outside of the service area.