Nurse Case Manager

2 weeks ago

Fort Worth, United States JPS Health Full time

Who We Are
JPS Health Network is a $950 million, tax-supported health care system in North Texas. Licensed for 578 beds, the network features 75 locations across Fort Worth, with John Peter Smith Hospital --home to Tarrant County's first and only Level 1 Trauma Center, only psychiatric emergency services site, and the largest hospital-based family medical residency program in the nation - and more than 40 community-based clinics. All told, our network employs more than 7,200 people.

Acclaim is our multispecialty medical practice group featuring over 300 providers serving the JPS Health Network. Specialties range from primary care to general surgery and trauma. The Acclaim group formed around a common set of incentives and expectations supporting the operational, financial, and clinical performance
outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

Why JPS? We're more than a hospital. We're 7,200 of the most dedicated people you could ever meet. Our goal is to make sure the people of our community get the care they need and deserve. As community stewards, we abide by three rules:

1. Own it.Everyone who wears the JPS badge contributes to our journey to excellence.
2. Seek joy.Every day, every shift, we celebrate our patients, smile, and emphasize positivity.
3. Don't be a jerk.Everyone is treated with courtesy and respect. Smiling, laughter, compassion - key components of our everyday experience at JPS.

When working here, you're surrounded by passion, diversity, and dedication. We look forward to meeting you

For more information, visit www.jpshealthnet.org.
To view all job vacancies, visitwww.jobs.jpshealthnet.org/ or www.teamacclaim.org.

Job Description:

Description: The Nurse Case Manager Outpatient PRN provides guidance and direction and acts as a resource to department team members to enhance patient care. The Nurse Case Manager Outpatient 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. The Nurse Case Manager Outpatient works in continuous partnership with patients and their family members, as well as clinic, hospital and post-acute partners, along with community based organizations, to achieve the desired outcomes. Using a defined process, the Nurse Case Manager Outpatient, identifies patients through risk stratification, establishes care plans and goals and coordinates care and services through the continuum of care with the goal of enhancing patient health, improving adherence to health programs and reducing health care costs. This position integrates population management, care transition, utilization and quality management functions to enhance the quality of clinical outcomes and patient satisfaction while achieving the desired financial and resource utilization outcomes.

Typical Duties:

  1. In conjunction with data analytic tools, payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination including but not limited to, preventive health care, disease management, behavioral health screenings and interventions, care opportunities, etc.
  2. Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-cost, high-need, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.
  3. Manages and supports the assigned population with moderate to complex care needs throughout a defined episode of care.
  4. Aids patient navigation through the care continuum with the goal of preventing and/or reducing readmissions, admissions, avoidable ED visits and ensuring that care is provided the right time, place, person and location.
  5. Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health, dieticians and specialists in order to provide ongoing care coordination.
  6. Provides care management services to assigned patients telephonically and face to face. Travel as needed to provider offices, hospitals, patient homes and post-acute settings may be required. Local travel may be required to perform duties at multiple sites.
  7. Manages effective transitions in care by facilitating warm hand offs with various interdisciplinary team members, physicians and community partners.
  8. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
  9. Assists patients with medication management and compliance, including a medication review, and makes referrals to other care team members such as a pharmacist to promote medication adherence.
  10. Provides education and coaching regarding chronic disease/s, self-management, community resources, etc. to support and empower patients to take a more proactive role in managing their health, well-being and shared decision making.
  11. Coordinates warm hand off to primary care providers and other partners throughout the care continuum when patient has a transition in care or completes the necessary wellness activities.
  12. Documents case management processes and interventions as outlined by department guidelines.
  13. Performs other job related functions as assigned.

Qualifications: Required Education and Experience: Bachelors 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.
Required Licensure/Certification/Specialized Training: 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 may be obtained subsequent to hire. Must be maintained throughout employment. Valid Drivers License in good standing.
Preferred Education and Experience: Masters Degree in Nursing from an accredited college or university.
Preferred Licensure/Certification/Specialized Training: Certified Case Manager (CCM) through the commission for Case Management Certification or American Case Management (ACM) certification through the American Case Management Association.

Location Address:
2500 Circle Drive
Fort Worth, Texas, 76119
United States

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