Monday - Friday 8 - 4:30
We re searching for an RN Case Manager (SPC) to serve the assigned SPC patient population at both Children s Hospital & Medical Center and Nebraska Medicine. The RN Case Manager acts in an expanded health care role to collaborate across the continuum with their assigned SPC care team, inpatient case management, social work, primary care, members of community health care teams, and patients/families to ensure the delivery of quality, cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient s health status. Integrate evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centered, promoting quality and efficiency in the delivery of health care. Communicate effectively amongst diverse patient populations and providers. In partnership with the specialty pediatrics care team, the Case Manager RN leads care coordination within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team.
- Identifies targeted, high-risk populations within clinic site(s) per Provider referral, risk stratification, registries, and/or patient lists.
- Assesses the health care, educational, and psychosocial needs of the patient/family.
- Uses standardized assessment tools such as psychosocial assessments, screenings, functional assessments, and health risk assessments.
- Develops individualized patient/family education plans. Instructs and counsels patient/family regarding acute/chronic illnesses, the use of prescribed treatments and medications, care coordination, and psychosocial needs.
- Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care and integrate health promotion into their lifestyle.
- Responsible for developing a comprehensive, individualized plan of care and targeted interventions.
- Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
- Continually monitors patient/family response to plan of care and revises the care plan as indicated.
- Collaborates with Providers, patients, families, and members of health care teams across a continuum of care settings and the community.
- Fosters a team approach and includes patient/family as active members of the team.
- Takes the lead in ensuring the continuity of care which extends beyond the clinic boundaries.
- Serves as liaison to acute care hospitals, specialists, post-acute care services and community agencies.
- Provides follow-up with patient/family when patient transitions from one setting to another.
- Completes timely post-hospital follow-up activities including medication reconciliation, Provider or Specialist follow-up appointments, review of discharge instructions, condition specific education, coordination of care, and assists in problem solving barriers.
- Maintains comprehensive medical record documentation on the appropriate information systems and databases using required documentation and billing guidelines.
- Utilize EHR activities to manage preventative care for patients.
- Assist in the development of adequate workflows to ensure patient care needs are met.
- Proactively reach out to patients most in need of care by utilizing EHR reporting tools.
- Facilitate the use of bulk ordering and communications with groups of patients.
- Manage the care of high risk patients using EHR patient outreach tools, which may include but not limited to: managing health maintenance, creating and tracking patient goals and completing appropriate patient assessments via telephone.
- Works with clinic and leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and the Patient Centered Medical Home delivery of care model.
- Participates in teaching/coaching clinic staff in the management of patient conditions. Assesses staff educational needs and develops educational programs. Promotes opportunities and activities.
- Demonstrated written and verbal communication skills.
- Ability to apply the nursing process to acute patient care to achieve outcomes.
- Current knowledge of the healthcare environment, including community resources and financial systems.
- Working knowledge of basic computer programs such as word, excel. Knowledge of smart phone use.
- Bachelor s degree from an accredited college or university in nursing required.
- Minimum 5 years in nursing required, preferably in a pediatric setting.
- Current and valid Nebraska RN license/RN Compact license required.
- Current and valid Basic Life Support (BLS) through the American Heart Association is required.
- Certification from a nationally recognized case management organization preferred
Children's Hospital & Medical Center - Omaha