RN-Case Manager

JOB Purpose:

The Registered Nurse in an integral member of the interdisciplinary health team and assumes responsibility for the standard of nursing care delivery in the clinic setting.  He/she is responsible for providing the utmost standard of care to be delivered to the clinic’s patients.

RESPONSIBILITIES:

1. Serves as a linkage between providers and patients to improve coordination of services and information flow.
2. Dialogues with medical providers in order to educate them concerning options available for the members having behavioral health disorders, dental issues, and referral needs/options.
3. Provides self-management support.
4. Provides ongoing phone contact and follow-up with patients.
5. Provides coordination and linkage to general medical services, dental services, and behavioral health services.
6. Works with patients’ providers to customize services to best meet patient’s needs within the parameters of available services.
7. Coordinates, reviews and maintains daily logs for reporting purposes and for weekly review.
8. Meets with patients, care providers, and other staff as needed to develop and coordinate treatment plans; meets with patient family members if needed.
9. Interfaces with and refers patients to other supportive services as appropriate. Such as our referral office, or Take-Charge Program.
10. Keeps current lists of referral sources.
11. Initiates and provides accurate patient educations based on assessment of patient needs and clinic standards of nursing care, and documents in patient record.
12. Attends meetings as requested by supervisor.
13. Utilizes supervision: identifies and reports to PI committee to identify issues and recommendations for improvement in patient care coordination.
14. Participates in PI activities and provider training, and participates in professional development activities when asked.
15. If needed, demonstrates consistent, accurate, timely, and thorough patient screenings according to policy and procedure for all patients.
16. If needed, accurately assesses patient’s acute, chronic, and preventive health needs as well as communicate patient status to provider.
17. Follows protocols and performs accurate and thorough work-ups and check-ins of all patients if needed.
18. Demonstrates safe and accurate skills such as sterile dressings, EKGs, pulmonary treatments, x-rays, lab draws, obtain IV access, immunizations, injections, as well as correct drug administration (including dose, method, adverse reaction protocols, acknowledging the patient’s 5 drug rights) etc.
19. Anticipates the needs of providers related to patient visits and assists providers as needed/necessary.
20. Provides accurate patient education based on patient’s needs and clinic’s standard of nursing card, as well as provide accurate documentation in each patient’s chart appropriately.
21. Exhibits caring qualities consistent with the values of FHCSO.
22. Assumes role of patient advocate to ensure health needs are met, to include responding to patient phone messages and requests in a timely and professional manner.
23. Documents all provider orders, nursing actions, and interventions on patient record consistent with guidelines and utilizes approved abbreviations when documenting for a provider.
24. Appropriately screens patients on-site and via telephone for appropriateness and timeliness of care per approved careening protocols and standing orders.
25. Knowledgeable of and follows all established Infection Control guidelines and OSHA standards and participates in staff training events.
26. Performs screening when needed.
27. Educates patients related to diabetes, smoking cessation, take charge, etc.
28. Knowledgeable of the Performance Improvement Program
29. When needed, performs approved laboratory testing, to include proper handling and labeling of all test samples, according to health center policy and procedure, and as allowed by COLA guidelines.
30. Keeps patients and families informed of situations that affect the clinic visit; i.e. extended waiting times, seeing provider other than originally scheduled, etc.
31. Floats to any of the satellite sites if needed.
32. Performs other duties incidental to work.
33. Works in harmony with others exhibiting a positive attitude and a commitment to the mission and vision of the health center. Strong leadership and guidance with appropriate prioritization skills.
34. Proactively assumes the responsibility for the standard of nursing care delivery and customer service in the clinical areas.
35. Knowledgeable of the scope of practice for all nursing disciplines as described by the Nurse Practice Act. Experience in ambulatory care and /or emergency department.
36. Participates in designated activities and projects for PCMH as assigned by the Chief Medical Officer.
37. Shows commitment to team effort, work well with others, supports group objectives, and participate in staff meetings and team problem solving.
38. Demonstrates commitment to team projects
39. Able to step in and document for providers if needed.
40. Management of immunizations and ordering of supplies.
41. When dealing with patient grievances, work with patient advocate to ensure patient satisfaction and care.
42. Maintains up to date state licensure and required certifications.
43. Follows mission and vision statement
44. All other duties as assigned by supervisor