Outpatient RN Case Management

Patient Care

• Delivers direct patient care within the scope of licensure and in accordance with HMG policy and protocols.
• Prioritizes patient care by implementing physician orders and nursing procedures.
• Recognizes important changes in patient condition and reacts appropriately.
• Executes care understanding standing orders and clinical protocols, applying independent nursing judgement and critical thinking.
• Trips patient calls and symptoms prioritizing care needs and scheduling appropriately to clinical judgement.
• Identifies patients requiring crisis intervention and initiates appropriate emergency response procedures while coordinating with providers and crisis services.
• Manages Nurse Visit schedule and effectively communicates problems, concerns or issues to the Office Supervisor/Manager appropriately and promptly.

Patient Education

• Provides patient and family education on disease management, medications, and preventive care.

Documentation

• Ensures accurate, timely documentation in the EHR.
• Affirms proper labeling, handling and documentation for patient specimens.
• Affirms all patients are correctly identified prior to providing and/or documenting care.
• Maintains monitoring and documentation storage conditions (medications, vaccines) and takes corrective action as needed.

Clinical Leadership and Operations

• Serves as a clinical resource and provides oversight and delegation to unlicensed staff.
• Attends annual clinical facilitator training to support staff onboarding, training, competency validation, and ongoing education.
• Manages clinical supply and vaccine inventory in accordance with Centers for Disease Control and Prevention guidelines.
• Leads and/or participates in daily safety huddles, staff meetings, and process improvement initiatives.
• Supports infection prevention and control protocols.

Case Management

• Coordinates care among behavioral health providers, primary care, specialty care, emergency departments, hospitals, skilled nursing facilities, and community agencies.
• Performs transition-of-care outreach following emergency department visits, psychiatric hospitalizations, and medical admissions.
• Maintains accurate care management documentation and patient registries.
• Supports patients enrolled in Chronic Care Management (CCM), Behavioral Health Integration (BHI), Collaborative Care Model (CoCM), Transitional Care Management (TCM), and other value-based care programs.
• Tracks and monitors quality metrics including depression screening, suicide risk assessment, follow-up after hospitalization, medication adherence, and preventive health measures.
• Identifies patients requiring proactive outreach based upon quality measures and risk stratification.
• Promotes continuity of care across healthcare settings.
• Supports organizational initiatives focused on population health and value-based reimbursement.
• Participates in quality improvement projects designed to improve patient outcomes and patient satisfaction.

Work Contact Group

• Physicians and residents at various levels of training.
• Patients, patient’s families.
• Outpatient office staff personnel.
• Some HMC dept. personnel.
• Representatives from laboratory pharmaceutical companies.

Reporting Relationships

• Reports To (position): Nurse Manager, Nurse supervisor and/or Practice Manager / Director.
• Supervises (position(s)): Supervises-clinical staff in absence of Nurse supervisor/manager.