RN CASE MANAGER -

Patient Care

• Patient Centered Medical Home/ Specialty Practice: Adhere to and promote core expectations.
• Identify Appropriate Patients: Utilize established procedures including census review, risk screens, and referrals.
• Data Collection: Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate.
• Assessment: Assess the patient's clinical, psychosocial status and current treatment plans.
• Needs Assessment: Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources.
• Orders and Referrals: Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment.
• Reports and Records: Maintain computer-based tracking system and compile required reports and records.
• Collaboration: Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities.
• Goals: Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members.
• Plan of Care: Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources.
• Discharge Planning: Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team members.
• Variances: Intervene when variances occur in patient individualized treatment plan.
• Resources: Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes.
• Interventions: Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary.
• Treatment Conference: Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management.
• Education: Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control.
• Information: Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team.
• Continuity of Care: Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant others.
• Care Plan: Incorporate recommendations and/or services of interdisciplinary team members in the care plan.
• Communication: Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfaction.
• Documentation: Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely manner.
• Orientation: Participate in orientation, continuing education of staff RN's and other health care team members as appropriate.
• Quality: Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentation.
• Committees: Attend meetings and represent department or Hospitals within Hospitals related committees or the community, as assigned by supervisor.
• Development: Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops.
• Patient Safety 1: Follow patient safety-related policies, procedures and protocols.
• Patient Safety 2: Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes.
• Patient Safety 3: Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk.
• Patient Safety 4: Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner.
• Patient Safety 5: Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right."
• MEDICATION: (UPC and CPC Only) Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings.
• PATIENT CARE: (UPC and CPC Only) Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions

Qualifications

• Education: Program Graduate (Essential); Nursing Graduate (Nonessential).
• Experience: 1 year directly related experience (Essential).
• Credentials: RN in NM or as allowed by reciprocal agreement by NM (Essential); CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days (Essential).
• Physical Conditions: Light Work (Essential).