RN Case Management

Under the direction of the Case Management Supervisor, this position is responsible to assess, diagnose, plan, implement, and evaluate patients enrolled in complex case management to facilitate and coordinate the patient’s plan of care with the provider in the Priority Care Program. The Case Manager will perform a comprehensive assessment and care plans on each delegated patient annually, assist with any care coordination needed and provide ongoing education and resources to the patient/caregiver to help prevent avoidable ER utilization.

The Case Manager will attend patient appointments in the Priority Care Clinic on site with the patient and carry out all orders given by the provider. This may include medication orders, lab orders, referrals, patient teaching, basic wound care, EKG, SQ and IM injections, ear lavages, venipuncture. The Case Manager will collaborate with the medical team in an effort to help improve the patient’s health outcomes and reach stability in their health issues so that the patient may graduate from the Priority Care Program and resume care with their assigned Primary Care Provider.

The RN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Be flexible, adaptable and motivated.
• Have a positive attitude and be a team player.
• Obtain and document all pertinent patient information and notes in Next Gen.
• Strive for a positive and professional relationship with providers, patients, and families.
• Provide effective communication with various health care providers, including specialists.
• Attend all scheduled patient office visits in the Priority Care Clinic and execute provider orders in a timely manner.
• Evaluate patient’s level of acuity based on clinical criteria and update level as needed.
• Level 1A- HIGH acuity
  - Weekly Case Manager follow up: end-stage health conditions, severe, acute and/or chronic health concerns.
• Level 1B- MODERATE acuity
  - Biweekly Case Manager follow up: multiple comorbidities, acute and chronic health concerns, recent hospitalizations.
• Level 2A- LOW acuity
  - Monthly Case Manager follow up: stable, needs minimal follow up, conditions well controlled, near return to PCP.
• Communicate with patient and document contact in Next Gen according to patient’s assigned acuity level.
• Complete annual comprehensive assessment. Assessment must be initiated within 30 days from the referral date and completed within 60 days.
• Comprehensive assessment to include patient’s clinical history, self-reported health status and goal, care plans with
• Goals and Barriers with progress towards goals, medication reconciliation, social history, caregiver resources, hearing and vision, available benefits, community resources, interdisciplinary care team members, next scheduled Case Manager follow up, health screenings, life planning activities, assessment summary and conclusion.
• Create a comprehensive and working care plan following NCQA, CMS, and Health Plan guidelines with input from the interdisciplinary care team and patient or caregiver.
• Set and prioritize appropriate patient centered SMART goals.
• Be present at the patient’s appointment in the Priority Care Clinic and carry out all orders given by the provider.
• Keep an updated brain sheet on each patient with all past/present medical history, clinical data and specialty appointment information.
• Ensure all recent medical records are obtained prior to the patient’s scheduled appointment and present to the provider.
• Review the provider’s orders with the patient/caregiver to ensure understanding; provide any education or teaching needed. Orders may include medications, labs, referrals, basic wound care, EKG, SQ and IM injections, ear lavages, and venipuncture.
• Outreach patient after a transition of care has occurred within 3 days by reviewing plan of care with the patient, follow through on discharge orders and update their care plans accordingly.
• Update care plans with changes in patient’s medical status.
• Be knowledgeable regarding disease processes, labs, and medications to ensure the…