RN Bilingual Case Manager - Breast & Cervical Cancer Outpatient Program

About the Job

General Summary of Position

The RN Case Manager provides community-based care coordination and clinical support as a member of a small, collaborative team serving predominantly Spanish-speaking women age 40 and older residing in Baltimore City. This office-based role focuses on telephonic patient engagement, triage, and clinical assessment to support access to appropriate services and continuity of care. The RN Case Manager utilizes strong clinical judgment and acute care experience to identify patient needs, coordinate resources, and promote positive health outcomes.

This State grant-funded position offers a fixed annual salary of $86,000 and is eligible for annual cost-of-living increases. Some travel to Baltimore City is required. The role offers a structured, consistent workflow while delivering meaningful and rewarding impact within the community. Facilitates the delivery of quality cost effective patient-centered care from pre-admission through post-discharge timeframe. Ensures that the care is designed to meet individualized patient outcomes.

Primary Duties and Responsibilities

* Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.

* Collaborates with the multidisciplinary health care team to develop and coordinate the plan of care.

* Communicates daily with direct care givers and case management triad regarding patient and family responses to plan of care identification of problems discharge planning and payer concerns such as LOS. Collaborates with utilization review team members on medical necessity determinations. Refers cases that need intervention.

* Communicates with patient family and/or significant other to identify and clarify patient and family goals.

* Communicates with patient family and/or significant other health care team external case manager and facility to address issues relating to transition from acute to post-hospital care. Escalates issues to physician advisors and or supervisors as necessary.

* Conducts a pre/post admission assessment in order to identify patients for case management based upon indicators on the high-risk screen. Performs a comprehensive assessment incorporating data obtained from other disciplines to identify patient-specific problems or needs related to diagnosis treatment and discharge planning.

* Demonstrates competency in area of specialty to meet age specific biopsychosocial and spiritual needs of patients served.

* Disseminates and applies knowledge in order to meet the educational needs of the health care team community patients and families. Uses available readmission prevention risk identification systems to manage assigned population and communicates plan of care and barriers to the interdisciplinary care team. As appropriate communicates daily with direct care givers and case management triad regarding readmission risk factors Care Transition plans and post-acute services.

* Evaluates and documents the patient's response to the plan of care and achievement of outcomes. Makes recommendation for modifications to the plan of care as indicated. Evaluates effectiveness of clinical pathways through outcome analysis variance tracking and problem identification.

* Manages a caseload of patients from admission through discharge and readmission when appropriate. Identifies essential resources needed to implement the plan of care. May initiate discharge plan in collaboration with the patient/family and healthcare team and meet mutually set goals as clinically desirable and as financially feasible. Communicates with patient family and/or significant other health care team external case manager community resources and facility to address issues relating to transition from acute to post-hospital care.

Delegates specialized patient care needs and planning to team members such as community health advocates peer recovery coaches complex case manager and social workers. May maintain a post-discharge caseload of assigned patients with timely telephonic case management calls in order to ensure the discharge and follow-up plans are adhered to by the patient.

* Manages own professional growth in the area of managed care care management other health care financial trends clinical practice readmissions and research.

* Manages patient care according to clinical pathways and/or multidisciplinary plan of care and/or management care contracts by directing decision making and identifying and managing barriers that impact on patient care outcomes. Identifies delays and communicates appropriately.

* Maintains knowledge of regulatory agencies' requirements for discharge planning necessary criteria for admission to various care settings and Medicare's/Medicaid's reimbursement methods for different levels of care.

* Participates in Performance and Service Improvement teams. Assists in program evaluation through…