Description
SUMMARY
The RN Case Manager (CM) will serve as an integral member of the healthcare team to improve the clinical and operational performance of patients across Primary Care, Behavioral Health, Wellness, and Dental Clinics within CRNA. The role will focus on assessing, organizing, planning, and coordinating the delivery of care in conjunction with the healthcare team; and providing nursing services such as medication and disease management teaching and monitoring. In addition, the CM works with the contracted vendor to ensure continuity of chronic care management of Medicare patients. The CM will collaborate closely with the Case Management Assistant(s) for administrative support.
JOB DUTIES
Provides initial and ongoing education on the relevant disease state and counseling on prevention, harm reduction, and adherence support.
Coordinates patient care with other members of the medical team.
Regularly assesses progress toward goals and identifies patients who are not adhering to their medical plan and provides outreach to assess barrier to care, provide education, and assist clients in accessing medical care and treatment.
Liaises with external chronic care management (CCM) vendor and provider to ensure requirements of CCM program are met.
Collaborates with CHAs and BHAs to assist and support care of CRNA patients.
Collaborates with the quality manager, reviewing and providing trends in clinical data and participating in initiatives that improve outcomes and quality indicators.
Prepares documentation for care conference and participates in case discussions.
Coordinates client care during transitions, ensuring medications are reconciled and follow-up visits are scheduled.
Assists with the development and implementation of corporate policies and procedures.
Utilized ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved, patient-specific protocols and order sets.
Documents care in accordance with EMR requirements and nursing standards.
Assigns appropriate administrative work as necessary to the referral coordinator.
Oversight and fulfillment of Core Operational Activities: Referral Management
Fax Distribution
Outside Orders
Did Not Keep Appointment (DNKA) Follow-up
Records Requests
VA Authorization
DME Requests
Travel Vouchers
Perform other duties as assigned.
NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES
Ability to utilize a trauma sensitive approach to interacting with clients.
Current knowledge of nursing practices, patient rights, federal and state regulations and consistently observes HIPAA.
Strong understanding and sensitivity to Alaska Native culture and lifestyle, with demonstrated experience working effectively with Alaska Native population.
Skills in operating personal computer using a variety of computer software.
Strong clinical and assessment skills.
Outstanding communication skills, self-motivation, organization and flexibility.
Commitment to improve care, build relationships with patients, and embrace a collaborative work style.
Ability to manage multiple priorities and tasks concurrently and meet deadlines.
Requirements
MINIMUM QUALIFICATIONS
Current State of Alaska Nursing license (or attainment of Alaska licensure prior to starting work).
Current BLS certification.
Two (2) years of nursing experience.
PREFERRED QUALIFICATIONS
Five (5) years of nursing experience.
Two (2) years of case management experience in a primary care or FQHC setting.
