Outreach Nurse Case Manager
4 days ago
Bluestem Health is seeking a highly skilled and compassionate Outreach Nurse Case Manager to join our team. As a key member of our healthcare team, you will play a vital role in helping patients and their families navigate and access community services, resources, and adopt healthy behaviors.
Key Responsibilities:- Establish trusting relationships with patients and their families, providing general support and encouragement.
- Provide ongoing follow-up, basic motivational interviewing, and goal setting with patients/families.
- Follow-up with patients via phone calls, home visits, and visits to other settings where patients can be found.
- Help patients set personal health-related goals and attend appointments.
- Provide referrals for services to community agencies, as appropriate.
- Help patients connect with transportation resources and give appointment reminders in special circumstances.
- Exhibit excellent working relations with patients, visitors, and staff, effectively communicating Bluestem Health's mission.
- Work closely with medical providers to ensure patients have comprehensive and coordinated care.
- Work cooperatively with other clinical personnel assigned to the same patient.
- Be knowledgeable about community resources appropriate to the needs of patients/families.
- Be responsible for providing consistent communication to the care team to evaluate patient/family status, ensuring that provided information and reports clearly describe progress.
- Act as a patient advocate and liaison between the patient/family and community service agencies.
- Record patient care management information in the EMR and other software no later than 48 hours after patient contact.
- Attend regular staff meetings, trainings, and other meetings, as requested.
- Manage assigned caseload of patients.
- Maintain HIPAA compliance at all times.
- Responsible for developing a plan of care, service coordination, and linkage to key community services.
- High School Diploma or its equivalent, required.
- Registered Nurse or LPN, preferred.
- Background in motivational interviewing/health coaching preferred.
- Written and oral fluency in Spanish and English is preferred.
- Experience working in a multi-cultural setting.
- Experience working in a community-based setting for at least 1 to 2 years preferred.
- Knowledge of some medical terminology preferred.
- Basic computer skills required, electronic medical record (EMR) experience preferred.
- Ability to initiate and maintain positive working relationships with Bluestem Health staff and other organizations.
- Understand the community served, community connectedness.
- Good communication skills, such as listening well, and using language appropriately.
- Ability and willingness to provide emotional support, encouragement, and motivation to patients.
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