Lead RN Case Manager

Description

The Case Manager is responsible for managing chronic illness patients with regards to the Patient Centered Medical Home (PCMH) to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality outcomes. Is proactive in assisting the Center to achieve the goals of the PCMH. Supports and follows through with the vision, mission, goals and objectives of the Family Healthcare of Hagerstown.

Lead Responsibilities: In addition to carrying out clinical case management duties, the Lead RN Case Manager serves as a resource and support person for clinical support staff. Lead responsibilities may include coordinating workflow, providing day-to-day guidance, assisting with problem solving, and performing other lead functions as assigned by the supervisor. Specific lead duties will be determined and directed by the supervisor based on departmental needs.

• Ensuring quality of care by coordinating treatment provided to patients diagnosed with chronic illnesses.
• Collaborates with provider and practice staff in identifying appropriate patients including diabetics, patients with depression and hypertension for case management utilizing PCMH guidelines. Ensures patient’s labs are up-to-date and appropriate education is provided.
• Conducts initial and periodic assessments for case managed population. Prioritizes patients according to complexity, need, and required follow-up. Documents the assessments in the patient’s chart in the EHR/EDR.
• Maintains databases on case managed population. Maintains accurate and timely documentation to include care plan, education and resources provided, within 24 hours of patient contact. Appropriately schedules patients and provides accurate coding for face to face visits.
• Identifies and effectively utilizes community resources to meet the needs of patients/families. Works with the Center’s Community Outreach Worker for those who have barriers to access to care.
• Formulates and implements a case management plan that addresses the patient’s identified need by assessing barriers, resources, and PCMH goals. The plan is documented in the patient’s chart in the EHR/EDR.
• Promotes patient self-management by reviewing PCMH Care Plans with patients/families to improve compliance and involvement.
• Performs all duties and responsibilities in accordance with Maryland’s Board of Nursing requirements and in accordance with basic principles and guidelines of professional nursing.
• Is proactive in contacting patients who fail to keep scheduled case management appointments or as directed by providers.
• Provides additional education, resources, and training for the PCMH ‘High Risk’ Patients to improve their high-risk behavior.
• Manages distribution of medication vouchers, reconciliation of monthly invoices and maintains a data base of medication dispensed to include monetary amounts and number of patients served.
• Coverage of the triage phone to include evaluating the priority of the need for an appointment and the appropriate time frame.
• Coordination of patient care for all FHH practices. Examples may include but are not limited to the following, Dental OR cases & children seen on the mobile unit:
  Assessment of children at high risk not receiving treatment & follow-up with Child Protective Services; mental health patients follow up with community resources and medication monitoring, obtaining documentation of hospital/ER admissions or specialist reports, facilitating presented plans of care/orders from home health to confirm medication lists and current PCP and collaboration with provider/support staff to encourage compliance with treatment.
• Assists with grant management to include providing statistics and data related to grant criteria.
• Maintenance…