RN, Case Manager

Job Details

Job Summary:

Serves as an advocate and care coordinator for at risk patients, including hospital discharge, non- compliance for management of chronic disease, newly diagnosed for chronic disease or cancer, frail elderly or emergency room high utilization. The Case Manager is responsible for making an in depth assessment of a client's needs and provides appropriate interventions that will improve the outcome, provide appropriate access to care, decrease re-hospitalization or provide other support systems for the management of the condition.

Supervisory Responsibilities: N/A

Essential Duties and Responsibilities:

• Conducts a thorough needs assessment based on the risk factor or diagnosis provided at the time of referral. This may include a medical history, functional abilities and social components including family support systems, ability to function independently, ability to obtain medication and understand the prescription, language skills and medical insurance status.
• Arranges and coordinates various services based on the needs. These may include public or private programs, not for profit organizations, transportation, in home support services, medical insurance, patient and family education, home health, medication use and others. Assists with paper work necessary to obtain services.
• Maintains adequate knowledge of resources available and conducts additional research when indicated or necessary to resolve complex cases.
• Acts as advocate between agencies and clients to ensure timely interventions. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.
• Demonstrates the knowledge base necessary regarding resources and health care services to appropriately assist the client and communicate effectively with the medical team.
• Demonstrates ability to manage the case through the continuum of care towards providing timely interventions and an appropriate outcome. Provides the adequate care coordination and effectively communicates the interventions and progress with the health care team. Conducts timely follow-up assessments.
• Maintains appropriate documentation including but not limited to client's information, diagnosis and medical history, communication with service providers, details of the referrals issued, plans, goals and outcomes.
• Makes recommendations as to changes in the direction of projects based on informed and acquired knowledge of trends and community changes.
• Conducts or participates in community meetings as deemed appropriate for the current assignments or potential opportunities of development.
• Integrates support functions effectively with the clinic services and operations.
• Assists with opening new opportunities for funding or program growth by staying informed and establishing a network of community resources.
• Participates in organizational performance improvement projects related to the functions of the current activities.