Enhanced Care Management RN

SUMMARY:

The Registered Nurse Staff functions as a part of a "Care Team" for the Enhanced Care Management Program (ECM). Collaborates and communicates with members, caregivers/family support persons, and other providers to promote wellness, recovery, independence, resilience, and member empowerment. Offers more intensive case management services to qualifying members, with a focus on providing community-based healthcare services, including creating care plans and formalized goal setting. Provides professional nursing care by utilizing the nursing process to care for patients within an assigned unit as assigned. Coordinates care provided at the Clinic as directed by department management and medical providers. Cooperates with other members of the health care team in meeting the total needs of patients. Participates in patient teaching. Directs and assists in activities of ancillary personnel.

RN ESSENTIAL FUNCTIONS:

1. Utilizes the nursing process of assessment, nursing diagnosis, plan intervention and evaluation to ensure that resources of the Department are used to provide for patient’s care, comfort and safety. Prioritizes plans and organizes the delivery of comprehensive nursing care as provided by the healthcare team.

2. Collaborates with the Licensed Independent Practitioners to identify medical management, patient goals and nursing interventions.

3. Demonstrates technical/clinical competence in providing nursing care that is appropriate or the department assigned. Can manage change with the workload. Initiates emergency measures, which require independent judgment and action

4. Acts as an advocate for patient rights by initiating and maintaining confidentiality, privacy, safety, patient education and active collaboration with the healthcare team to promote the patient’s best interest.

5. Accountable for assignments and their completion within scheduled work hours. Maintains appropriate time records. Works independently with minimal supervision or direction.

6. Orientates new staff members as needed. Functions as a clinical resource to LVNs, Medical Assistants (I & II) and ancillary staff.

7. Supports, promotes and functions within the Clinic and unit policies and procedures and the Nurse Practice Act.

8. Demonstrates proficiency in managing resources and utilizing equipment in a safe manner. Actively contributes to cost control by managing time, resources and supplies effectively.

9. Administers and controls medications.

10. Attends a minimum of nine (75%) unit staff meetings annually to be successful. Accountable for reading minutes of monthly meetings. Participates in conferences and education programs, as required, and Quality Improvement activities and issues that monitor to improve care provided.

11. Assesses patients and patient populations need for case management within the health care continuum

12. assesses the multidimensional domains of: physical functioning, psychological functioning; social supports and financial resources

ECM Essential Functions:

1. Conducts concurrent utilization activities according to established criteria and guidelines

2. Evaluates and collaborates with all members of the health care team to document patient status and variances, working toward achievement of patient goals/optimum quality and cost outcomes.

3. Conducts comprehensive health assessments with each member

4. Develops and implements and individualized care plan with each ECM member

5. Documents all aspects of a client care plans, including goals met as well as goals

forthcoming goals

6. Maintains complete and disciplined documentation of activities.

7. Reports monthly activities and data

8. Documents level of engagement such as frequency and duration of ECM encounters

9. Documenting client disengagement as well as engagement

10. Educate members about Health Maintenance

11. Educate members about health Maintenance and disease prevention

12. Advocate with primary care providers to ensure quality treatment and/or

Care access

13. Serve as the primary point of member contact; assess member needs, manage

Care and services, and ensure effective communication among members, caregivers

providers and community support.

14. Provide members with appropriate information regarding referrals, ensuring linkage

15. Work collaboratively with hospital staff regarding member’s care

16. Evaluate progress and update goals of members

17. Conducts regular reviews of patient’s chart to ensure quality services and provided

documented accurately.

18. Complete all documentation within the timeframes per protocols

OTHER RESPONSIBILITIES:

Assesses and cares for the geriatric patient with knowledge and clinical skills of the aging process.

2. Assesses and cares for the pediatric patient with knowledge and clinical skills of the growth and development process.

3. Maintains and demonstrates professional skills through self-development and participation in on-going hospital in-service education.

4. Maintains accountability for own practice and for aspects of nursing care delegated to peers, LVNs and other ancillary personnel.

5. Utilizes the chain of command in situations where resolutions for the issue exceeds one’s authority.

6. Demonstrates knowledge and the ability to apply ethical and legal principles to practice.

7. Communication:

a. Clearly and accurately communicates pertinent aspects of the patient’s care to other members of the Patient Care team.

b. Documentation in patient records will be problem oriented and will provide relevant, factual, and accurate information.

c. Documentation in the Patient Record will always be legible. Entries in the patient record will be dated, timed, and signed with title.

8. Maintains positive and caring interpersonal relationships with patients, families, and fellow employees.

9. Offers and accepts constructive criticism and incorporates suggestions into nursing practice.

10. Supports and promotes safety standards. Identifies risk situations and intervenes appropriately.

11. Demonstrates clinical competence by successful completion of the Annual certification of standardized procedures. Must have current knowledge of Universal Precautions as employees may have to deal with potential exposure to Blood-borne Pathogens.

12. Other duties as assigned from time to time.

SUPERVISORY RESPONSIBILITIES:

None

EDUCATION, KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE:

1. Knowledge of hospital and nursing policy and procedure and the function of other departments within the facility.

2. Previous clinical experience in a patient care setting with successful completion of orientation and training to the point of competence.

3. Bilingual (Spanish/English) Preferred

4. Knowledge of and diligent effort being made on assembling and following up on Comprehensive assessments and care management plans

5. Ability to discuss sensitive matters and to respect confidentiality

6. Analytical skills to review documented medical information and use it for Care plans

7. Ability to work independently and as part of a group

LICENSES AND CERTIFICATIONS:

1. Current licensure to practice registered nursing in the State of California.

2. Current CPR certification and ACLS certification is required.

AGE OF POPULATION SERVED:

Newborn  Infant/Pediatric  Adolescent  Adult  Geriatric X All  No Patient Care

PHYSICAL REQUIREMENTS:

1. Manual dexterity with fine motor ability to operate and handle equipment used in the department.

2. Ability to hear the spoken word, auscultate for physical assessment skills and monitor alarms.

3. Ability to see written type with corrective lenses.

4. Ability to stand for up to several hours at a time.

5. Ability to climb stairs.

6. Able to perform tasks of lifting, turning, and transferring patients with assistance.

7. Sits, stands, bends, lifts, and moves intermittently during working hours.

8. Preforms other duties as assigned.