We are currently searching for an RN Case Manager to serve the patient population at Childrens Physicians (CP) and is the core of care planning. The RN Care Manager acts in an expanded health care role to collaborate across the continuum with the CP care team, specialty care management, inpatient case management, social work, members of community health care teams, and patients/families to ensure the delivery of quality, cost-effective health care services. The RN Care Manager assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patients health status. The RN Care Manager integrates 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. This role communicates effectively amongst diverse patient populations and providers. In partnership with the CP care team, the Patient Care Coordinator and RN Care Manager, lead 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 office(s) per Provider referral, risk stratification, registries, and/or patient lists.
- Assesses the health care, educational, and psychosocial needs of the patient/family in collaboration with the Patient Care Coordinator.
- Uses standardized assessment tools such 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.
- Utilizes Healthy Planet activities to manage preventative care for patients.
- 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.
- Creates preventative care plans for identified patient populations.
- 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 office 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.
KNOWLEDGE, SKILLS AND ABILITIES
- 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.
EDUCATION AND EXPERIENCE
- Bachelors 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.
- Certified Pediatric Nurse (CPN) certification preferred.
Children's Hospital & Medical Center - Omaha