Under the general supervision, provides care coordination, clinical utilization management and discharge planning for an assigned case load. This role is patient focused, outcome-oriented and based on general and specialty professional standards and functions within an interdisciplinary practice model. This role is accountable for the continuity and integration of patient care services.
II. Principal Responsibilities and Tasks The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
1. As part of the interdisciplinary team lead by the Primary Care Provider, the case manager has an integral role in the continuity and integration of patient care services. A. Collaborates with the interdisciplinary team to identify patients most likely to benefit from care coordination services. B. Assesses the patient’s risk factors and needs for care coordination, clinical utilization management services, discharge planning and identifies appropriate preventative services. C. Develops a care plan and treatment goals with the patient and/or family. 2. Provides the patient and/or family education about relevant diseases and their management, including medication management. A. Identifies self management resources including health education classes and support groups to achieve care plan goals. B. Coaches the patient and/or family on how to respond to acute and/or worsening symptoms in order to avoid unnecessary hospitalizations. Educates patients and/or family on the availability of same day appointments. 3. Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options. Tracks patients’ progress towards care plan goals and revises the care plan as indicated. 4. Assists with the maintenance of patient registries to manage specific patient populations and improve disease outcome measures. Assists with the implementation of clinical decision support tools, referral and test tracking, and preventive medicine reminders. 5. Develops effective working relationships with physicians, nurse practitioners, nurses, allied health professionals (e.g. social workers, psychologists, etc.), medical assistants, and referral coordinators. 6. Models effective customer service behaviors. Identifies and acts on opportunities to understand and respond to the customer. 7. Takes the lead in ensuring the continuity and consistency of care which extends beyond practice boundaries. Serves as a liaison to acute care hospitals and post-acute care services to facilitate comprehensive discharge planning and follow-up care.
Education and Experience
1. Graduation from an accredited school of nursing is required; a Bachelor’s degree is preferred.
2. Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required.
3. Three years of clinical nursing experience is required.