Rn Case Manager printable pdf download

Job Description

Position Title: RN Case Manager

Position Summary: The RN Case Manager is a practice-based RN who directly supports CSHC’s

highest risk patients. In collaboration with other members of the healthcare team, the RN Care Manager is

responsible for organizing, coordinating, and providing care coordination and care management services

to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor

outcomes.

Primary Responsibilities:

Case Management Systems:

1. Manage CSHC high-risk patient registry

a. Oversee systems for identifying high risk patients through EMR, referrals, registries

from health insurance payers

b. Ensure validity of registry; collaborate with Information Technology on registry

functionality.

2. Develop a tracking system for patient care coordination and care management across the

continuum, including care transitions, Primary and Specialty care.

3. Act as clinical liaison for Payer Based Care Management programs, including the Senior

Care Options program and the One Care (“Dual Diagnosis”) Program.

Direct Patient Care:

1. Conduct comprehensive assessment of patients’ physical, mental, and psychosocial needs

2. Develop care plans to prevent disease exacerbation, improve outcomes, increase patient

engagement in self-care, decrease risk status, and minimize hospital and ED utilization

3. Utilize behavioral strategies help patients adopt healthy behaviors and improve self-care in

chronic disease management. Promote self-management goals.

4. Assist patients in navigating the health care system. Coordinate Specialty care, follow-up on test

results and other care coordination needs.

5. Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of ED visit

notification

6. Partner with external case management programs to coordinate care

7. Ongoing evaluation and documentation of patient progress/ risk status Document in EMR;

communicate with care teams

8. Document in EMR

Patient-Center Medical Home:

1. Pro-actively support PCMH initiatives related to care coordination

2. Pro-active member of care teams in team-based care initiatives

3. Partner with PCMH staff to develop integrated care management programs

Rn Case Manager