Registered Nurse; RN - Case Manager | McGreevy Clinic

Location:

Avera Medical Group McGreevy-7th Avenue

Worker Type:
Regular

Work Shift:

Day Shift (United States of America)

Pay Range: $27.75 – $41.25 (Actual pay rate dependent upon experience)

You Belong  part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

Accountable for supporting patient care navigation in the clinic setting. The RN’s primary responsibility is to manage care for the patients of the primary care practice to promote effective education, self‑management support, and timely health care delivery. This will include developing and monitoring care management processes and supporting primary clinical teams with these efforts. It will also include identifying the high‑acuity patient population and working to ensure care coordination for this patient population.

The position involves some patient triage. The RN will work with the clinic leadership and medical director (lead physician) of the practice to develop this position to best serve the needs of the patient panel and the primary care teams. This individual will work closely with the leadership of Care Coordination/Medical Home and others to support the development, maintenance, and reporting of quality measures within the medical home model.

• Work with all clinical teams as a resource on care management of all practice patients, including educating the patient about self‑management tasks they can undertake to gain greater control of their health status and managing patient care in the health care continuum to achieve optimum outcomes in a safe and cost‑effective manner.
• Collaborate with physicians, providers, and practice staff in identifying appropriate patients for care management, and provide leadership for patient care teams.
• Work with social services and nursing to identify, plan for, and provide an appropriate follow‑up plan of care for patients, communicating this plan of care to patient families, medical providers, hospital staff, community support, other agencies and departments.
• Provide follow‑up contact with patients as indicated to ensure compliance with recommendations – medications, lab/x‑ray, specialist visits, PCP visits, dieticians, CDE, etc.
• Review monthly status reports, dashboard results, and other information related to clinical care delivery. Communicate with physician groups regarding statistical and financial impact of care delivery.
• Serve as a resource for clinic care team education on changing payor requirements. Collaborate with payer case managers for additional services when appropriate.
• Participate in regular team meetings and peer review activities.
• Anticipate the needs of this patient population, ensuring necessary documentation and pre‑visit planning is completed or requested before patient visit.
• Promote patient self‑management and empower patients/families to achieve maximum levels of wellness and independence.
• Assess barriers when patients have not met treatment goals, are not following a treatment plan of care, or have not kept important appointments.
• Determine and complete appropriate referrals.
• Oversee the development, procurement, and adoption of patient self‑management educational resources used by the primary clinical teams.

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily, including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

• Registered Nurse (RN) – Board of Nursing. An active license in the state of…