Description
Job Summary: The Case Manager participates as an integral member of the interdisciplinary care team at TCH. Key roles are coordination of services for patients, focusing on those who face difficulty navigating the healthcare system. The RN Case Manager provides follow up for specialty referrals and supports patients in self-care management and identifies relevant community resources. The Case Manager makes efforts to collaborate with outside service providers to provide seamless transitions of care and provide patient education while assisting with access to applicable resources. The RN Case Manager works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and the health care team to promote timely access to needed care, comprehensive and continuity of care, and the enhancement of patient well-being from a trauma informed philosophy.
Essential Duties and Responsibilities:
- Coordinates with other medical facilities, i.e., specialists, hospitals, labor and deliver, emergency room to ensure continuity of care
- Manages follow-up of specialty referrals, including clinically indicated services outside of the organization (e.g. social services such as housing and transportation assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment, home health and hospice care)
- Coordinates care pertinent to patient needs
- Communicates information from the healthcare team to patients as needed
- Uses motivational interviewing concepts to discuss and identify self-management goals and develop care plans with high-risk patients
- Educates patients when appropriate regarding healthy lifestyle and their acute chronic conditions
- Conducts risk assessments for identified populations (HIV, OB) and discusses strategies to reduce risk with patients based on findings
- Educates patient on care team resources and processes at TCH that impact their care
- Resource Assessment and Barrier Reduction:
- Systematically tracks treatment response and monitors patient (in-person or by telephone) for changes in clinical symptoms and treatment side effects or complications
- Tracks patient follow-up and clinical outcomes. Documents in-person and telephone encounters in the registry and uses the system to identify and re-engage patients
- Follows up with high-risk patients regarding missed appointments to identify barriers and plan accordingly
- In consultation with the medical provider, facilitates treatment plan changes for patients who are not improving as expected or for patients that may need more intensive or specialized healthcare
- Assist with accessing patient care items including procuring durable medical equipment or medication when patient resources are limited
Additional Duties and Responsibilities:
- General RN responsibilities (Patient Care)
- Functions as a member of an interdisciplinary healthcare team
- Collaborates with clinical QA/QI director to facilitate data collection and conduct improvement activities in specific patient populations
Requirements
Work Experience: Minimum of three years’ experience in Nursing. Two to three years’ experience in leadership. Community Health Center experience preferred.
Education, Certification and Licensure: Post secondary education in Nursing. Maintain current, active license with the State of Alaska as a Registered Nurse in good standing. Current CPR Certification
Work Location and Remote Work Requirements:
This position may be performed remotely from a location approved by TCH. Preference may be given to candidates located in Alaska. Remote work locations will be considered on a case-by-case basis and must be approved by TCH prior to employment. Periodic on-site attendance at TCH is required for meetings, training, program activities, community events, and other operational needs.
