RN Case Manager
The overall goal of the nurse case manager position is to achieve positive patient outcomes and manage quality of care across the continuum of care. The nurse case manager will first and foremost serve as an advocate for our patients. In this capacity, they will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The nurse case manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.
Key daily functions for the nurse case manager may include:
Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
Build relationships with preferred acute care providers (hospitalists, specialists)
Direct referrals to preferred providers.
Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
Provide high intensity engagement with patient and family.
Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
Enhance a collaborative relationship to maximize the patients/familys ability to make informed decisions.
Address advanced care planning including treatment goals and advance directives.
Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs
Obtain onsite and EMR access at priority facilities
Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
Submit required documentation in a timely manner and in appropriate computer system.
Participate in surveys, studies and special projects as assigned.
Strong interpersonal, communication and critical thinking skills are required.
Ability to work autonomously is required.
Fluent in English
Eeducation / SPECIALIZED KNOWLEDGE requirements:
Bachelors degree in nursing or RN with BA/BS in healthcare related field preferred.
Certification in case management is preferred. Hospital, healthcare setting experience is preferred
Minimum of 2 years of utilization review, case management, home health and/or discharge planning experience is preferred
Dedicated Senior Health is transforming health care for seniors. We provide big answers to big problems in health care delivery.
Dedicated Senior Health is a full-risk primary care market leader with an innovative philosophy, unique physician culture and end-to-end customized technology. These things allow us to provide world-class primary care and coordinated care to the most vulnerable population moderate- to low-income seniors who have complex chronic diseases.
Through our innovative operating model, physician-led culture and empowering technology, we are able to drive key quality and cost outcomes that create value for patients, physicians and the overall health system.
Our model allows us to practice medicine the way it should be practiced: by recruiting focused physicians and reducing their doctor-to-patient ratios, we increase patients time during each monthly appointment and help foster stronger doctor-patient relationships. Our model also drives and enhances compliance with treatment plans.
As a result of our efforts, our patients realize lower hospital admissions. Their overwhelming response to our approach is reflected in our aggressive, organic growth and net promoter scores in the low to mid 90s, which is unheard of in any industry. Read more about our results and the value of the Dedicated Senior model.
As a company, we are making a difference in the lives of seniors and in the health care system overall.