Chronic Disease Case Manager- RN or LPN

POSITION SUMMARY

The Chronic Disease Case Manager provides chronic disease education, and case management support to both primary care patients and clients/patients living with HIV. The position works with the Clinical Director of Coordinated Care, Director and Assistant Director of Remote Care Management, HIV Medical Director, and Positive Connections Program Coordinator, and is under the general supervision of the Chief Medical Officer and/or Primary Care Providers. The Chronic Disease Case Manager will enroll referred and participating patients in the Remote Care Services including Chronic Care Management and Remote Patient Monitoring. Services are provided via phone, telehealth, secure messaging, or in person. This mode of delivery may also apply to working with HIV + clients/patients for case management services and support. The nurse will ensure all required paperwork, screenings, and education remain current and are completed in a timely manner. The nurse will continue to provide frequent monitoring/evaluation, documentation, follow-up, and collaboration to patient’s care team. This position demands the ability to interact with Federal, State, and local agencies to maximize the resources and to achieve program development goals.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform essential functions.

Essential Functions Statement(s)

Develop a Medical Services Plan for clients/patients receiving ongoing Chronic Disease Case Management within thirty (30) days of enrollment following the standards and MCM Assessment form(s) required by ADH.
Review Medical Services Plan for all active MCM clients/patients based on their acuity level following the standards required by ADH.
Participate in case conferencing with the client's/patient’s medical services provider at a minimum of every six (6) months or as required by acuity level in the standards of care.
Facilitate client/patient transfer and inactivation in compliance with ADH policies.
Document client/patient interacting in the progress notes, on required forms and in the CAREWare database.
Provide referrals for medical evaluation and treatment.
Manage case consultation with physicians, dentists, Registered Nurses, Advanced Practices Nurses, Physician Assistants and Service Access Specialist.
Provide case management of HIV medication therapy to include education of client/patient concerning side effects, monitoring disease process to include lab values, monitoring client/patient adherence and tolerance of medications.
Coordinate medical care and disease management activities.
Provides education/in-services to nursing staff as appropriate.
Provide education about HIV, its transmission, complications, risk education and harm education.
Conduct adherence assessment and interventions to include counseling, education and referral, as appropriate.
Provide nutritional assessment and interventions to include counseling, education, and referral, as appropriate.
Provide interventions and education about a variety of issues, as appropriate to both client/patients assessed need for intervention and the MCM's trained skills. Interventions may include (but are not limited to): 1) Healthful living habits 2) Holistic approach to wellness 3) Safer sex practices 4) Partner notification and testing 5) Prevention of exposure to opportunistic pathogens 6) Teaching women to perform breast self-exam 7) Needed immunizations
Staff Relations/Team Support: 1. Assists team members in the provision of Part B medical services to HIV infected/affected clients/patients. 2. Provides Education/In-Services to CARE PROGRAM clients/patients and staff as appropriate. 3. Performs other necessary duties as required by the Chief Clinical Officer to provide quality health care services.
Performs other necessary duties as required by the Director of Remote Care Management and Positive Connections Program Coordinator to provide primary health care services/HIV services.
Maintains current knowledge of immunization protocols as outlined by the Arkansas department of Health.
Participate as needed with outreach events directed by the Community Health team.
Participates in the center’s quality improvement activities and performs duties in accordance with applicable standards.
Assists in special projects as directed by the Director of Remote Care Management/Positive Connections Program Coordinator.
Provide patient-centered care that incorporates culturally and linguistically appropriate services.
Educate patients about health maintenance activities, adoption of healthy behaviors, and support services available in the community.
Communicate with patients and families about health care issues and the importance of developing self- management goals and healthy behaviors.
Assist in coordinating seamless transitions of patient care across multiple care settings by using combined expertise of care team members.
Employ active listening techniques during interactions with patients, families, and team members.
Use health information systems efficiently to manage and improve care at the individual and system levels and ensure the delivery of timely and accurate information.
Participate in care team huddles to prepare and coordinate patient care activities.
Incorporate quality indicators for specific disease states and /or patient variables into patient care plans.
Other duties as assigned

POSITION QUALIFICATIONS

Competency Statement(s)

Accountability - Ability to accept responsibility and account for his/her actions.
Active Listening - Ability to actively attend to, convey, and understand the comments and questions of others.
Adaptability - Ability to adapt to change in the workplace.
Analytical Skills - Ability to use thinking and reasoning to solve a problem.
Business Acumen - Ability to grasp and understand business concepts and issues.
Communication, Oral - Ability to communicate effectively with others using the spoken word.
Change Management - Ability to encourage others to seek opportunities for different and innovative approaches to addressing problems and opportunities.
Communication, Oral - Ability to communicate effectively with others using the spoken word.
Communication, Written - Ability to communicate in writing clearly and concisely.
Conceptual Thinking - Ability to think in terms of abstract ideas.
Conflict Resolution - Ability to deal with others in an antagonistic situation.
Deductive Reasoning - Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.
Decision Making - Ability to make critical decisions while following company procedures.
Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
Detail Oriented - Ability to pay attention to the minute details of a project or task.
Ethical - Ability to demonstrate conducts conforming to a set of values and accepted standards.
Honesty / Integrity - Ability to be truthful and be seen as credible in the workplace.
Initiative – Ability to make decisions or take actions to solve a problem or reach a goal
Interpersonal - Ability to get along well with a variety of personalities and individuals.
Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
Motivation – Ability to inspire oneself and others to reach a goal and/or perform to the best of their ability.
Negotiation Skills - Ability to reach outcomes that gain the support and acceptance of all parties.
Organized - Possessing the trait of being organized or following a systematic method of performing a task.
Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
Reliability - The trait of being dependable and trustworthy.
Responsible – Ability to be held accountable or answerable for one’s conduct.
Safety Awareness - Ability to identify and correct conditions that affect employee safety.
Self Motivated – Ability to be internally inspired to perform a task to the best of one’s ability using his or her own drive or initiative.
Tactful - Ability to show consideration for and maintain good relations with others.
Team Builder – Ability to convince a group of people to work together towards a goal.
Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
Working Under Pressure - Ability to complete assigned tasks under stressful situations.

SKILLS & ABILITIES

Education: Associate’s Degree in related field; High School Diploma or GED required.

Experience: At least one year of experience in a medical facility.

Computer Skills: Microsoft Word and Excel; and customized software. Ability to learn and adapt to changing technologies as the organization changes. Ability to learn and utilize electronic record keeping systems.

Certificates & Licenses: Current RN or LPN license in appropriate state required. CPR and TB required at hire date and annually thereafter.

Other Requirements: The ability to relate with effectiveness to the public. The ability to effectively perform several duties of the department and the ability to organize and achieve goals in a busy setting as well as effectively communicate with internal and external stakeholders. Willingness to attend continuing education related to this role.

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