Nurse Case Manager

4 weeks ago

Fort Worth, Texas, United States JPS Health Network Full time

Job Title: Nurse Case Manager - Outpatient

Job Summary:

The Nurse Case Manager Outpatient provides guidance and direction to department team members to enhance patient care. This role is responsible for providing care management services and support to an assigned population with the purpose of improving patient health outcomes via a coordinated approach.

Key Responsibilities:

  • Identify patients at risk for poor outcomes and coordinate care and services through the continuum of care.
  • Develop and execute comprehensive plans of care for high-risk, high-cost, high-need, high-utilizing populations.
  • Manage and support assigned populations with moderate to complex care needs throughout a defined episode of care.
  • Aid patient navigation through the care continuum to prevent and/or reduce readmissions, admissions, avoidable ED visits, and ensure that care is provided at the right time, place, person, and location.
  • Serve as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members to provide ongoing care coordination.
  • Provide care management services to assigned patients telephonically and face-to-face, and travel as needed to provider offices, hospitals, patient homes, and post-acute settings.
  • Manage effective transitions in care by facilitating warm hand-offs with various interdisciplinary team members, physicians, and community partners.
  • Utilize advanced conflict resolution skills to ensure timely resolution of issues.
  • Assist patients with medication management and compliance, including medication reviews, and make referrals to other care team members to promote medication adherence.
  • Provide education and coaching regarding chronic disease, self-management, community resources, and empower patients to take a proactive role in managing their health, well-being, and shared decision-making.
  • Coordinate warm hand-offs to primary care providers and other partners throughout the care continuum when patients have transitions in care or complete necessary wellness activities.
  • Document case management processes and interventions as outlined by department guidelines.

Requirements:

  • Bachelor's Degree in Nursing from an accredited college or university.
  • 3-5 years of clinical experience and/or care coordination and discharge planning, utilization management, case management, or other cost/quality management.
  • Current RN licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state.
  • Current CPR/BLS certification, which may be obtained subsequent to hire and must be maintained throughout employment.
  • Valid Driver's License in good standing.

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