Nurse Case Manager - Transitional Clinic
Nurse Case Manager - Transitional Clinic
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Salary Not Disclosed
1 Vacancy
Job Description
This position is within our Comprehensive CARE Center a transitional clinic that assists with patients that have recently been discharged from the hospital helping to coordinate care educate and reduce readmissions. In collaboration with a multidisciplinary team the nurse case manager is responsible for patients who are identified as high or potential high utilizers of the system to assess and assist in the coordination of patients care across the continuum. Position functions as a clinician case manager and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization.
Job Tasks
1. Assessment:
Identify and assess high risk patients with chronic disease complex medical and psychosocial needs referred to the CARE Center
Complete a thorough assessment with patients history including medical physical social emotional psychological and financial needs that will assist the care team in developing a care plan
Identifies barrier to health care to include Social Determinant of Health (SDoH) and medical that focuses on the prevention of readmissions.
2. Care coordination:
Provide telephonic guidance advice and support to patients
Accepts responsibility for patients Transition of Care to provide postdischarge followup to ensure medication reconciliation followup appointments with PCP or specialist and other special assistance as needed
Communicate with multidisciplinary team any pertinent findings causing a delay in care coordination to ensure safe and efficient services
3. Medication Reconciliation:
Interview patient/family to identify home medications
Assess patient/family knowledge of their medications
Assess patient/familys ability to afford medications
Review discharge medications
4. Implement plan of care for the patient by performing evidencebased interventions and treatments specific to the diagnosis or problem of the patient: administers treatment such as lab draws start IVs injections nebulizer treatments wound care as directed by provider and monitors patients according to their needs and acuity level. Performs symptombased standing orders and plan of care.
5. Accurately create a care plan based patients assessed chronic diseases complex medical and psychosocial needs.
6. Educate patient on complex medical needs in multiple learning environments including but not limited to (telephonic phone calls virtual support group CARE Center visits remote patient monitoring home visits).
7. Promote and provide patient selfmanagement educating patients on disease medication access to care and community resources/referrals to improve clinical outcomes and increase selfefficiency.
8. Conduct individual and group education sessions to assist patient/family in socialemotional needs that are impacted by living with a chronic diagnosis.
9. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.
10. Communicate with patients primary care team (physician nurse practitioner social worker case manager etc.) regarding changes in patient status and/or care plan.
11. Participate in teambased care. Willingly accept direction from providers and serve as a clinical resource to medical assistants and other practice team members. Communicate proactively.
12. Establish an effective and appropriate means of communicating and collaborating with providers team members payers and ancillary services to ensure safe and efficient services.
13. Participate in educational programs and inservices supporting quality improvement and clinical efficiency initiatives.
14. Assist with special projects and other duties as assigned.
Qualifications :
Education & Training: Current Maryland RN license required. Completion of a Bachelors of Science degree in Nursing preferred.
Work Orientation & Experience: Three (3) years nursing care experience required. Case Management experience preferred.
Skills & Abilities:
Demonstrate skill in a) clinical case management; b) performing complete assessments; c) monitor assess and record patient progress against a plan of care; d) effective critical thinking skills both written and oral; e) facilitating patient access to community resources; and f) age appropriate interpersonal interactions
Ability to a) communicate and collaborate effectively with both internal and external customers (Medical Staff multiplespecialty team management staff external organizations and general public); b) assess adapt and calmly respond to changing and/or crisis environment; c) make independent decisions consistent with current policies procedures and ethical standards; d) direct care to include starting lines performing nebulizer treatments lab draws; e) prioritize work assignments and manage time effectively to complete duties; and f) assist in data analysis and computer literate in word processing Excel and data management skills.
Additional Information :
All your information will be kept confidential according to EEO guidelines.
Compensation:
Pay Range: $37.92$53.59
Other Compensation (if applicable):
Review theUMMS Benefits Guide
Remote Work :
No
Employment Type :
Fulltime
Employment Type
Full-time
