Outpatient RN Case Manager
2 weeks ago
Position Overview
As an integral part of the Population Health Management (PHM) Team, the Outpatient Case Manager is responsible for collaborating with patients, healthcare providers, and family members to deliver comprehensive case management and enhance the effective use of services for individuals with intricate healthcare needs. This role involves identifying patients with chronic, complex, or catastrophic conditions through the case management process and initiating targeted case management in line with established program protocols. The Outpatient Case Manager will employ a multidisciplinary approach to address the diverse needs of various patient populations.
The primary objective of the PHM Outpatient Case Manager is to proficiently manage patients in an outpatient setting and during acute hospital episodes (in partnership with inpatient case managers) to ensure the delivery of appropriate care, facilitate safe transitions to home or other care levels, prevent unnecessary hospital readmissions, and address the medical, environmental, and psychosocial needs of patients throughout their care journey. The Case Manager serves as an advocate for patients and their families, connecting them with relevant resources and facilitating education to promote self-management and effective navigation of the healthcare system.
Key Responsibilities
- Engage with patients through face-to-face interactions or telephonic communication.
- Coordinate with other members of the PHM team or multidisciplinary care team to effectively manage patient needs.
This role will primarily involve telephonic interactions, supporting multiple physician practices or patient populations based on volume.
Core Responsibilities and Essential Functions
Assessment
- Evaluate all patient referrals to confirm eligibility for case management services.
- Conduct thorough assessments to identify the needs of patients and their families.
- Recognize high-risk areas, including medical, environmental, and psychosocial factors.
- Explore all available options and resources to meet client and family needs while promoting optimal health in a cost-effective manner.
- Collaborate with patients, families, physicians, and the multidisciplinary team to develop and adjust individualized care plans that address the needs and goals of high-risk patients with complex chronic conditions.
- Incorporate evidence-based clinical guidelines and preventive health protocols into care plans that are centered on the patient, enhancing quality and efficiency in healthcare delivery for high-risk populations.
- Establish processes to monitor patients across the healthcare continuum, focusing on safe transitions from hospital to home, nursing facilities, or rehabilitation centers, aiming to optimize resources and reduce avoidable readmissions.
- Align patient and family needs with appropriate resources to execute the care plan, utilizing both telephonic and in-person communication as necessary.
- Regularly prioritize and collaborate with patients, families, and healthcare providers to enhance patient engagement and clinical outcomes efficiently.
- Coordinate necessary patient care services and make appropriate referrals to team members for resource assistance.
- Emphasize wellness, disease management, and patient education to ensure adherence to the care plan and prevent complications from various conditions.
- Identify care gaps and collaborate with the team to address them.
- Facilitate member visits with primary care providers and specialists as required.
- Track care through data collection and analysis, evaluating processes systematically to assess the effectiveness of the case management plan in achieving desired outcomes and improving care quality, access, and cost.
- Manage performance feedback metrics to refine the care model, maximizing clinical, quality, and financial outcomes for the targeted population.
- Participate in team meetings to review current processes, provide and receive feedback, and discuss specific cases to enhance patient adherence to care plans, clinical outcomes, and satisfaction for both patients and providers.
Graduate of an accredited nursing program with a current RN license. A Bachelor's Degree in Nursing is preferred.
Licenses and Certifications Required:
- Registered Nurse (Single State) or RN - Multi-state Compact
- Basic Life Support (BLS) Certification
Minimum of 5 years of clinical experience, with prior case management experience required. Case Manager Certification (CCM) is preferred. Proficiency in Microsoft Office Suite and electronic health records is advantageous, along with experience in data collection and analysis.
Required Skills
Strong understanding of complex case management roles and processes. Excellent interpersonal skills to effectively interact with diverse practitioners, healthcare teams, community agencies, patients, and families. Ability to engage with the geriatric population over the phone and support the development of the PHM Case Management role. Demonstrated leadership qualities, including organizational and time management skills, effective communication, problem-solving, decision-making, and delegation abilities. Proficient in utilizing risk-stratification screening criteria and reviewing clinical data to identify patient healthcare needs.
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