Sr RN Case Manager Care Me Program Float

Sr RN Case Manager Care for Me Program Float at Optum summary:
The Sr RN Case Manager in the Care for Me Program works within primary care clinics to support patients with high-risk and chronic conditions by coordinating multidisciplinary care, facilitating patient education, and promoting self-management. This role involves developing and updating individualized care plans, conducting assessments, managing transitions of care, and ensuring compliance with healthcare standards. The position requires collaboration with healthcare teams, strong communication skills, and knowledge of evidence-based nursing practices to improve patient outcomes and reduce hospital utilization.
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The Clinic Case Manager is responsible for fostering collaboration and a team approach for successfully supporting patients with high-risk health conditions to navigate the healthcare system. Promotes empowerment by facilitating the role of an educator, resource, and advocate for patients and their families to ensure a maximum quality of life. Interacts and collaborates with multidisciplinary care teams, to include physicians, nurses, pharmacists, case managers, social workers, and other educators.

Acts as a clinic resource for the value-based population. Works in a less structured, self-directed environment and performs all delegated nursing duties within the scope of a RN license of the applicable state board of nursing.
Ensures compliance to contractual and service standards as identified by relevant health insurance plans. Adheres to policies, procedures, and regulations to ensure compliance and patient safety. Participation in Compliance and required training is a condition of employment.

Primary Responsibilities:

• Role embedded within the primary care clinic, working directly with patients, clinical and non-clinical teams

• Participates in the identification of a focused clinic patient panel, as defined by the manager of Medical Management

• Supports longitudinal care of the patient with chronic care conditions

• Communicates with patients, responding to patient questions via patient portal and other modalities

• Performs assessment of health conditions and implements care plan in collaboration with the member, caregiver(s), clinician(s), and/or other appropriate healthcare professionals to address need and goals

• Pursues appropriate interventions to reduce risk of condition exacerbation, ER and hospitalization utilization

• Performs medication reconciliation and collaborates with clinician partner as needed

• Conducts Motivational Interviewing and Self-Management Goal setting

• Provides patient education

• Creates referrals to appropriate agencies and resources

• Supports transition of care from Emergency Department or inpatient stay to outpatient setting

• Performs assessment of transitional needs

• Performs medication reconciliation

• Establishes and reviews contingency plan

• Provides patient education

• Assists with post discharge needs such as home health care, prescriptions, transportation, Durable Medical Equipment (DME), appointments

• Coordinates with providers to establish or update individualized plan of care

• Creates referrals to appropriate internal and external resources

• Achieves Quality Measures outcomes via reduction in HEDIS Gaps in Care

• Performs accurate and timely documentation in the electronic medical record

• Performs triage and clinical tasks within their scope of practice

• Participates in daily huddles and monthly clinic meetings, as required

• Prepares accurate and timely reports, as required

• Maintains continued competence in nursing practice and knowledge of current evidence-based practices

• Performs ongoing updates of the care plan to evaluate effectiveness, and to document interventions and goal achievement

• Maintains a working knowledge of community resources

• Serves as facilitator and resource for other members of the Medical Group clinical team

• Attends departmental…