Outpatient Nurse Care Manager

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How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well‑being of every person we serve. We are proud to have become a shining example of what’s possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people’s lives.

Day (United States of America)

As a member of the Population Health Management (PHM) Team, the Outpatient Case Manager works with members, providers and caregivers to provide intensive, comprehensive case management and increase efficient utilization of services for patients with complex needs. The role identifies chronic, complex and/or catastrophic cases through the case management process or referrals and initiates intensive case management according to program guidelines.

The PHM OP Case Manager effectively manages patients on an outpatient basis and during episodes of acute hospitalizations (in conjunction with inpatient counterparts) to assure the appropriate level‑of‑care is provided, optimize safe transition to home or the next level of care, prevent inpatient read‑missions and ensure that the patients’ medical, environmental and psychosocial needs are met over the continuum of care.

The Case Manager acts as an advocate for members and their families, linking them to other disciplines on the care team to facilitate patient/family education, navigation of the health care system, and identification of community resources as necessary.

• Matches patient/family needs to available and appropriate resources to carry out the plan of care; utilizes telephonic and face‑to‑face communication as appropriate.
• Prioritizes and collaborates with patients/families/healthcare providers regularly to optimize patient engagement and clinical outcomes efficiently.
• Coordinates patient care services necessary to meet patient needs; makes appropriate referrals to other team members.
• Emphasizes wellness, disease management and patient education to ensure compliance with plan of care and prevention of complications.
• Identifies care gaps and works with team to close them.
• Co‑ordinates member visits with primary care providers and specialists as needed.
• Reviews patient referrals to determine criteria met for case management; performs comprehensive assessment to identify patient/family needs; identifies all high‑risk areas (medical, environmental, psychosocial).
• Reviews all available resources and promotes optimum health in a cost‑effective manner.
• Collaborates with patient/family, physician and multidisciplinary team to develop and modify individualized plans of care addressing high‑risk patients with complex chronic conditions.
• Integrates evidence‑based clinical guidelines, preventive health guidelines, protocols, and other risk information into patient‑centric plans of care.
• Develops and utilizes processes that monitor patients across the health continuum with a focus on effective and safe transitions from hospital to home, nursing home or rehab facility, aiming to optimize resources and reduce avoidable acute care readmissions.
• Monitors care through data collection and analysis; evaluates processes utilizing a systematic approach to determine effectiveness of the case management plan in terms of desired outcomes and goals to improve quality, access and cost of care.
• Manages performance feedback metrics to refine the care model and maximize clinical, quality, and fiscal outcomes for the target population.
• Participates in team meetings to evaluate current processes, provide and receive feedback, review specific cases for improved patient adherence to the plan of care, clinical outcomes and patient/provider satisfaction.
• Performs other duties as assigned; complies with all Wellstar Health System policies, standards of work, and code of conduct.