RN Case Manager - Care Ally

About the role

At The South Bend Clinic, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Responsibilities

• Assumes an active role in the planning and implementing educational needs of assigned patients, with direct care team and need consultants: Diabetic Educator, pharmacy, dietary, wound care, etc.
• Coordinates assigned patients' clinical care plan in conjunction with the Primary Care Provider and with appropriate team members and communicates the plan to patient/family in a timely manner.
• Review services with interested patients and assist in enrolling them in the CCM program
• Provide all services necessary in order to execute an electronic care plan
• Determine an individual’s health and educational needs as a result of inbound and outbound phone calls, and review of medical records with patients
• Maintain communication with patients to measure no less than 20 minutes per month
• Collaborate with the patient's provider to facilitate appropriate physical, behavioral and social services
• Review care plans and make changes as necessary
• Provide patients with information regarding medical questions/concerns
• Examples of CM activities may include educating newly diagnosed patients about the disease and treatments; managing therapies; and drug administration and side effects
• Develops, manages, and drives clinical plan of care with physician and multi-disciplinary care team.
• Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure timely patient management and facilitation of services.
• Coordinates patient care across the care continuum to reduce fragmentation of care and addresses/ resolve system issues that may be impeding progress and quality of care for patients.
• Focuses on management of the complex patient with the goal of patient self-management, quality outcomes, and resource utilization goals.
• Identifies and refers patients for social worker intervention, as well as transitions of care follow up at home.
• Addresses complex clinical situations efficiently, to avoid unnecessary delays in care.
• Obtains the support of the social worker for complex social issues, behavioral problems, home and family issues, placements, guardianship, hospice, palliative care referrals, drug and alcohol abuse, and violence.
• Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post-acute care needs daily.
• Coordinates with post-acute partners and facilities to ensure efficient care and patient-centered transitions.
• Exhibits computer systems knowledge and proficiency as necessary to perform job functions.
• Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards.
• Performs other duties as assigned when appropriate.
• Adheres to HIPAA guidelines set forth in Clinic policies and procedures.

Requirements

• Minimum of an unencumbered license as a Registered Nurse in the state of Indiana.

Qualifications

• Must have experience in case management or care management (Certified Case Manager preferred)
• Must have experience with Medicare/Medicaid
• Experience with multiple EHR/EMR systems
• Ability to work collegially with staff members from multiple offices
• Ability to manage multiple patients simultaneously
• Ability to build and maintain relationships with patients, families and client providers
• A background in geriatric care, family medicine and/or long-term care (skilled nursing, home health, hospice, public health, assisted living) highly preferred
• A background and ability to work with populations with special needs
• Competence and experience with electronic charting
• Ability to multitask