Job Description

The RN Case Manager will support the mission of the Ozarks Community Health Center. Our mission is to provide greater access to quality, compassionate, and professional healthcare through our comprehensive health system and community partnerships.
Strives to provide intensive care coordination and care management, and address Social Determinants of Health for a medically complex population. Strives to meet the education needs of clinic nursing staff to allow them to perform daily functions related to providing care to patients of the community. Performs daily functions related to providing care to patients of the community. Actively and consistently contributes to department operations and communication. Behaves in a manner consistent with the mission of OCHC and performs other duties as requested.

Job Responsibilities

Identifies high risk patients through provider/nurse referrals or chart review and maintains an up-to date panel of patients in the ACO program and those who do not fall into a case management program. Collaborates with Care Coordinator and other staff to ensure a monthly touch is completed for all patients. Develops a care plan with patient-centered goals and action plans for each patient. Updates care plan at least twice a year and shares Personal Health Plan goals with the patient at every update. Frequently communicates and coordinates with providers and other care team members about patient needs, goals, and action plans, including preventive and chronic care. Documents accurate and detailed case management and care coordination notes within the EMR when patient contacts are made. Tracks and updates patients' care gaps, and documents efforts to close them. Collaborates with other staff to ensure that referrals, patient assistance, and prior authorizations are completed as needed for continuity of care. Provides education and resources on medical diseases, treatment, and medications to patients and families, and documents in EMR. Helps patients navigate the medical system including pharmacy and insurance. Monitors Case Manager workload and assists in handling provider requests. Assists rooming staff with on-the-floor nursing duties as necessary. Actively participates in department and clinical team meetings and activities. Functions as a clinical skill resource for OCHC clinic nursing staff. Performs clinical rounds at the clinics assuring nursing personnel compliance with job functions. Reports results of clinic rounds to managers and Clinic Administration team. Assures nursing personnel apply current nursing principles in the care of patients, performing within the limitations of the Missouri Nurse Practice Act when applicable, and within OCHC policy and procedure. Assures nursing personnel apply age and developmental level appropriate care to all patients served, including infant, pediatric, adolescent, adult, and geriatric patient populations. Maintains a close working relationship with the providers and clinic managers. Communicates needs of the clinics and clinic staff to the clinic managers and Chief Operations Officer. Maintains a working knowledge of regulatory requirements; The Joint Commission, HRSA, Vaccines for Children, and other agencies as needed. Shares knowledge with the clinic managers and nursing staff to facilitate continued survey readiness. Helps to set up competency requirements for skills, medication management, documentation, and medical emergencies. Trains new clinic nursing staff, to include EMR training. Completes an annual review and development of clinic nursing specific education via LMS. Completes ongoing training needs for all nursing staff, to include ad hoc training, mock codes, clinic evaluations, and hands-on skills training. Provides clinical chart audits to ensure nursing documentation, critical lab results and other necessary items are documented correctly. Acts as point person for LMS education for staff, assigning education, reviewing completion and communication with managers about LMS education. Assist with coordination and leadership of clinic nursing staff meetings. Other duties as assigned.

ROOMING NURSE RESPONSIBILITIES

Takes vital signs and documents all information correctly. Gathers and documents initial patient subjective data, reason for visit and uses correct template. Reconciles medications at every patient visit. Adding and deleting medications as needed. Asks all pertinent questions for quality measures as required and documents correctly to ensure quality QI data. Promptly assists provider in patient care as requested. (shots, x-rays, lab). All patient exam/ procedure rooms are cleaned in compliance with OCHC Infection Control Policy and in a timely manner. Stocks rooms and pulls expired supplies. Receives and handles patients medical related phone calls, relaying information to patients, as directed by provider. Documents in the medical record all information relayed. Obtains consent for procedures/ injections. Gathers all supplies as needed. Promptly handles nurse only visits. Vaccines/ injections and medications documented properly in patients EMR, including samples given. Order sets for in office procedures entered in EMR correctly. Ear wash, catheter, sutures, etc. Maintain competency on vaccine/ injection protocols and medication management, VFC and Stock. Monitor and complete assigned provider task list in a timely manner. Correctly sterilizes instruments and ensures sufficient supplies are available for procedures. Makes good use of downtime by working the downtime task list. Ensures EKG quality by using protocol and confirming test results interface in patients EMR. Reports any issues to IS team/Management. Reviews and understands policies/ protocols and adheres to them. Reconciles SMV and patient's EMR regarding vaccines. Completes VFC training modules annually. Passes annual skills competency. Passes annual medication math exam. Other duties as assigned.
Job Type: Full-time

Pay: $40,000.00 - $60,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Life insurance Paid time off Vision insurance
Experience:

Nursing: 1 year (Preferred) Case management: 1 year (Preferred)
License/Certification:

RN (Required)
Work Location: In person