Job Description

The RN Case Manager serves in an expanded healthcare role, collaborating with specialists, members of the healthcare team, and patients/families to ensure the delivery of quality, efficient, and cost-effective healthcare services. This position develops and assesses plans of care with the patient/family; implements, monitors, and evaluates all options with the goal of optimizing the patient's health status; and utilizes evidence-based clinical guidelines, preventive guidelines, and protocols to develop patient-centered care plans.

DUTIES AND RESPONSIBILITIES:

Consults and communicates care objectives with primary care providers, specialists, and community resources to assist patients in achieving healthcare goals. Identifies targeted populations through referrals from primary care providers and patient registries. Assesses the healthcare, educational, and psychosocial needs of the patient/family. Identifies and maintains relationships with referral and community resources. Collaborates with the primary care provider, patient, healthcare team, and community resources. Develops individualized plans of care with targeted interventions; monitors patient and family responses to the plan of care and adjusts as needed. Provides patients with self-management tools and support to enhance their ability for self-care. Maintains required documentation for all case management activities. Reviews current literature on engagement and communication strategies and incorporates best practices into the clinical setting. Maintains records and enters information into required databases. Assists the team in defining and working toward identified quality indicators (e.g., HEDIS/UDS, North Star, PCI initiative). Attends required in-service training and departmental meetings. Follows up on hospital admissions and ED visits daily. Works with and manages the most complex patients to ensure timely access to care and adherence to treatment plans. Performs other duties as assigned.

TYPICAL WORKING CONDITIONS:

The work environment characteristics described here are representative of those an employee encounters while performing essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions. Must be able to work in a stressful environment. This job operates in a professional office environment and utilizes standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. While performing job duties, the employee is frequently exposed to airborne particles within a healthcare facility or home-care setting. The noise level is usually quiet but may occasionally become disruptive when working with clients.

TYPICAL PHYSICAL DEMANDS:

The physical demands described here are representative of those required to perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions. Regularly required to use hands to finger, handle, or feel. Must be able to communicate through talking and listening to hear conversational voices. Frequently required to stand, climb stairs, walk, and sit. Must withstand frequent lifting, stretching, and other physical exertion. Ability to manage exposure to patient-care elements, including vascular access procedures, treatment of injuries, disposal of contaminated waste, cleaning and disinfecting equipment, and handling contaminated sharps. Occasionally required to stoop and kneel. Must occasionally lift and/or move up to 50 pounds. Specific vision abilities include close vision, peripheral vision, and the ability to adjust focus.

QUALIFICATIONS:

Basic Life Support/CPR training. Demonstrates customer-focused interpersonal skills to effectively interact with practitioners, interdisciplinary healthcare teams, community agencies, and patients/families with diverse opinions, values, and cultural or religious beliefs. Demonstrates excellent written, verbal, and listening skills. Demonstrates strong relationship-building and critical-analysis skills. Demonstrates ability to work autonomously and remain accountable for practice. Demonstrates ability to influence and negotiate individual and group decisions. Demonstrates ability to function effectively in a fluid, dynamic, and changing environment.

EDUCATION / EXPERIENCE / CERTIFICATIONS / LICENSES:

Associate Degree in Nursing required; Bachelor's Degree in Nursing preferred. Minimum of one year of experience in adult/pediatric medicine in a primary care/ambulatory care setting, home health agency, skilled nursing facility, or hospital medical-surgical unit within the past five years; or an equivalent combination of education and experience sufficient to perform job duties. Licensed as an RN in the State of Michigan. Certification in Case Management preferred.

Family Health Center reserves the right to modify the duties and functions of this job description based on organizational needs.