• RN Case Manager Longevity Clinic Days

    Posted Date 2 weeks ago(4/11/2018 1:00 AM)
    Requisition ID
    Nursing - Outpatient
    Position Type
    Regular Full-Time
    ICE Primary Care Care Management
    Day Shift
    Post End Date
  • Overview

    The RN Case Manager will promote wellness, improved outcomes and self-care within a defined population of patients with a long term condition(s) and complex health needs and support their appropriate utilization of health services. The RN Case Manager will provide patients who have chronic conditions, the support, the education and assistance in the prevention and/or maintenance of their disease and/or health and wellness state, thus increasing patient compliance with their treatment plan. The RN Care Manager will work with the individual patient, their families, and providers of care to develop and implement individual health plans and provide support to the patient in self-management to support the patient’s optimal functioning and improve collaborative coordination of care to reduce waste and inefficiency within the concept of the patient centered medical home.


      1. Works in conjunction with all care team members across the continuum to identify and proactively manage care needs and close care gaps of the highest risk patients with chronic conditions such as diabetes, uncontrolled hypertension, COPD, CHF, and age-related illnesses within the primary care setting to improve clinical outcomes.
      2. Actively manages assigned panel of high risk chronic care patients utilizing registries and reports.
      3. Coordinates care plans and conduct transitional care calls for patients with frequent Emergency Department utilization and those who are recently discharged for inpatient hospital admissions.
      4. Participates in patient-centered medical home (PCMH), aids in the development of clinic workflows and collaborates with physicians to develop and maintain current care plans with preventive services and chronic disease management.
      5. Identifies and stratifies high risk patients needing care management services to reduce re-hospitalizations in people with chronic illnesses (i.e. uncontrolled Diabetes, HTN, COPD, CHF, depression, out of range BMI and age-related conditions), socioeconomically disadvantaged, and/or the chronically mentally ill.
      6. Promotes patient, staff, provider and organizational satisfaction by coordinating and facilitating the delivery of quality and continuity of care while focusing on productivity and the cost effective utilization of resources.
      7. Provides education, support and outreach to patients over the phone and in person ensuring all aspects of care plan are met including but not limited to:
          1. Management of transitions in care delivery settings
          2. Review and update medications for reconciliation by provider
          3. Assess and address educational needs associated with chronic disease and prevention
          4. Assess and address any social and psychological determinants that impact disease management
          5. Facilitate adherence to quality metrics determined by quality programs e.g. UAMS, NCQA, CMS
          6. Facilitate transfer of information and communication among providers
          7. Educate and encourage adherence to regular primary care provider visits
          8. Serves as an advocate for the patient and family.
      8. Develops and supports a practice based care management model by providing on-site and telephonic services i.e. wellness, health coaching, goal setting, self-management techniques, disease management and case management including coordination with community services per Patient Centered Medical Home (PCMH) standards.
      9. Routinely scans medical literature for updates on clinical practice guidelines, new developments in the management of chronic diseases and communicates and disseminates information to staff.
      10. Facilitates regular patient follow up, education, crisis management, and coordination/support for people at risk or who are vulnerable because of their socioeconomic status and/or level of healthcare literacy who are reluctant to seek treatment due to limited knowledge of their condition and barriers to care.


    Required: Bachelors in Nursing (BSN), Valid RN License, minimum of 3 years of Registered Nursing experience with 2 years experience in a clinical environment.  Current BLS; excellent communication skills, strong work ethics and accountability, basic computer skills. Certification in Care Management (CCM or CCTM) or must obtain within 1 year of hire date.


    Preferred: 4 or more years of RN experience in a clinical enviroment. 




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