Nurse Case Manager

POSITION SUMMARY

Perform a variety of clinical care coordination and nursing duties in anoutpatient clinical setting. Collect, review, and analyze chronic diseasepatient information in accordance with protocol and distribution of data toproviders for action; develop and implement outreach efforts to facilitatepatient compliance/access; tracking patient's ER visits and hospital follow-upcare; identifying/ utilizing all appropriate available community resources; communicate,plan and coordinate with purchased referred care, as well as supporting caremanagement.

ESSENTIAL FUNCTIONS

1. Monitor and track patient referrals until the consultant or specialist's report is available, flagging and following up on overdue reports. Utilize clinical protocols to determine when a referral to a specialist is necessary. Monitor the timeliness and quality of the referral process.
2. Track patient laboratory and imaging tests until results are available, flag and follow-up on overdue or abnormal results bringing them to the attention of the assigned clinician. Notify patients/families/caregivers of lab and imaging test results.
3. Utilize clinical protocols to determine when imaging and lab tests are necessary. Notify and schedule patients for upcoming or overdue screenings. Perform follow-up on all newborn screenings.
4. Receive and share necessary patient treatment information with outside health care facilities, hospitals and emergency departments to coordinate emergency, comprehensive and hospital care.
5. Document and co-manage arrangements between primary care provider and specialists in the patient's medical record.
6. Systematically identify patients with unplanned hospital admission and emergency department visits. Coordinate referrals and billing with Purchased Referred Care.
7. Coordinate with families/caregivers for follow-up care following a hospital admission or emergency department visit. Implement a process to consistently obtain patient discharge summaries from the hospital and other facilities.
8. Collaborate with the patient/family/caregiver to develop/implement a written care plans for patients transitioning in/out of teams. Provide educational information to patients in conjunction with primary care providers related to treatments, procedures, medications, and continuing care requirements.
9. Responsible for managing assigned primary care provider patient panels.
10. Responsible for the electronic exchange of information with external entities, agencies and registries.
11. Assist with coordination of infection control and/or quality programs, advising or consulting with specified personnel about necessary precautions. Assists with data collection and analysis for quality improvement.
12. Serves as back-up to Registered Nurse or Medical/Triage Assistants as needed.
13. Properly enter/record patient information in electronic medical records. Maintain accurate, detailed reports and records.
14. Guide and train less-skilled nursing or healthcare personnel. Observe medical/triage assistants and visit patients to ensure proper nursing care. Provide or arrange for training or instruction of auxiliary personnel or students.
15. Work with tribal and other health personnel to design programs to improve the overall health of the community.

1. Completion of Nursing Program. Two (2) years nursing experience and one (1) year of case management experience in clinical setting preferred.

2. Associate Degree in Nursing, Bachelor Degree in Nursing preferred.

3. Current, active, full and unrestricted license as a Registered Nurse from any US state or the District of Columbia.

4. Current BLS/ACLS certification.