POSITION SUMMARY: The Nurse Case Manager (NCM) is responsible for managing patients with chronic diseases such as diabetes mellitus, hypertension, asthma, and obesity.  The NCM will promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes.  The NCM works in collaboration and continuous partnership with the patient and their family/caregiver(s), clinic providers and community resources in a team approach to minimize fragmentation of healthcare delivery systems, while increasing the patient’s ability for self-management and shared decision making.  This position is committed to the constant pursuit of excellence in improving the health status of the community.

POSITION-SPECIFIC COMPETENCIES/ESSENTIAL FUNCTIONS/DUTIES & RESPONSIBILITIES

• Case Management:

• Collaborate with Providers and practice staff in identifying appropriate patients for case management, utilizing established case management criteria.
• Oversee systems for identifying high risk patients through the EHR, referrals, and registries from health insurance payers.
• Identifies patients with chronic disease who are due for services and coordinates efforts to contact them to schedule needed services.
• Formulates and implements a case management plan that addresses the patient’s identified needs, issues, resources, and care goals. Establish a case management plan that is mutually agreed upon by the health care team and the patient/family.  Plans will include specific mutual self-management goals (SMG), objectives and interventions.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Performs follow-up calls for patients recently discharged from acute hospitalizations and are considered high risk for readmission.
• Maintains EHR databases on case managed population.  Maintain accurate and timely documentation in the case management template.
• Direct Patient Care:

• Provide direct nursing care as indicated and/or provide nursing back-up in the event of staff shortage, including nurse triage and provider assistance and support.
• Follow-up with patients within 24 hours on inpatient discharge and within 48 hours of ED visit notification.
• Develop care plans to prevent disease exacerbation. Ongoing evaluation and documentation of patient progress in EHR; communicate with care teams.
• Provide patient/family education regarding chronic disease, medications, self-management goals, etc., within the clinic setting, as needed
• Patient-Centered Medical Home:

• Proactively support Primary Care Medical Home initiatives related to care coordination.
• Participate in Quality Improvement Committee activities and trainings.
• Participate in care team huddles.
• Participates in community preventative health activities.
• Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
• Develops data-informed interventions to improve organizational performance in quality of care and cost of care metrics related to chronic disease
• Develops and conducts staff training as appropriate and necessary.  Oversee educational literature for patients and for staff.
• Performs other duties as assigned

POSITION REQUIREMENTS

Education:     Completion of Nursing Program required, Bachelor’s Degree in Nursing strongly preferred. LPN or RN license required.

Experience:   1+ years in ambulatory health care

                        Experience in disease management, population health efforts, case management or quality improvement preferred

Expertise:      Strong interpersonal and organizational skills

                        Proficient verbal, written and reporting skills

                        Microsoft applications (experience with Excel required), internet, email

                        Good record keeping methods

                        Ability to achieve measurable outcomes

                        Ability to handle multiple tasks

                        Knowledge of medical terminology

Language:     English fluency

Work Hours: 40 hrs/wk

Travel:            Minimal

Exposure:      While performing the essential functions of this job, the employee occasionally is exposed to fumes or airborne particles and toxic or caustic chemicals.  Additionally, the employee may occasionally be exposed to blood borne and other hazardous chemicals.  Finally, the noise level in the work environment can occasionally be quite loud.  In all cases, personal protective equipment will be provided to the employee in combination with adequate ventilation and other engineering controls to minimize the risk of exposure or other hazardous occurrence.

Physical:        Reasonable accommodation may be made for individuals with special challenges to perform these essential functions