RN Case Manager

2 weeks ago

Cookeville, United States nLeague Full time
Job DescriptionJob Description

Job Id: 63259

Position: RN Case Manager

Department: TN DOH

Location: 1100 England Drive Cookeville, Tennessee 38501

Duration: 09+ Months

Mode of Work: On-Site(Hybrid)

  • The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:
  • Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc.
  • Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information
  • Collaborate with primary care nurse and providers
  • Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider
  • Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.
  • Collaborate with other social workers to identify patient and community resources
  • Conduct case management activities
  • Work with hospitals for discharge planning, follow-up and education
  • Assist with obtaining patient records from hospitals
  • Assist in securing needed medical equipment through community partners
  • Conduct follow-up on care plans
  • Identify patients lost to follow-up or overdue for care and assist them in returning to care
  • May assist with specialty referral navigation
  • Schedule, coordinate, and track non-BCS specialist and imaging referrals
  • Assist with obtaining patient records from specialists and imaging centers
  • Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact information
  • Assist patients to locate and access low-cost prescription options such as patient assistance programs, discount retailers, etc.
  • May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies
  • Assist patient with applications for programs such as CoverRx and RxOutreach
  • May help with other regional primary care-based initiatives with a social work component
  • Documents in patient's record, updates consults, and tags provider and/or clinical staff as necessary
  • Provide patient education or find appropriate education resources
  • Expectations may include:
  • Complete onboarding and orientation
  • Participate in regional office and primary care clinical meetings as requested
  • Attend provider meetings as requested
  • Attend Health Councils and other community meetings to build relationships with social service agencies and promote health department services
  • Identify barriers to care or assistance experienced by our patients and seek ways to address them

Tools and Equipment:

1. Personal Computer

2. Telephone

3. Fax Machine

4. Printer

5. Scanner

6. Copy Machine

7. Calculator

8. Personal Vehicle

Other office related equipment as required

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