Ambulatory Nurse Case Manager / Patient Care Coordinators

Children's Nebraska•Omaha, NE

About The Position

The Nurse Case Manager serves the organization's patient population as a core member of the continuity-of-care team. The role collaborates across the care continuum with primary care and specialty care teams, inpatient case management, social work, community health care teams, and patients and families to support the delivery of quality, cost-effective care. The Nurse Case Manager assesses, plans, implements, coordinates, monitors, and evaluates services and care options to optimize patient health status. The position develops individualized care plans and targeted interventions, applies evidence-based protocols based on risk stratification, monitors patient and family responses, and revises plans as needed. It uses electronic health record tools to manage preventive care and outreach to high-risk patients, supports care transitions and follow-up after hospitalization, and coordinates services with hospitals, specialists, post-acute providers, and community agencies. The role also assesses health, educational, and psychosocial needs; provides patient and family education and self-management support; maintains required records; and works with clinic and leadership teams on process improvement.

Requirements

Bachelor's degree in nursing from an accredited college or university.
Minimum of 5 years of nursing experience.
Registered Nurse state licensure and/or compact state licensure upon hire.
Basic Life Support certification from the American Heart Association upon hire.
High proficiency in written and verbal communication.
High proficiency in applying the nursing process to acute patient care to achieve outcomes.
High proficiency in knowledge of the health care environment, including community resources and financial systems.
High proficiency in basic computer programs such as Word and Excel, and knowledge of smartphone use.

Nice To Haves

Experience in a pediatric health care setting.
Certified Pediatric Nurse certification.
Nursing Case Management Board Certification from a nationally recognized case management organization.

Responsibilities

Develop comprehensive, individualized plans of care and targeted interventions.
Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Monitor patient and family responses to care plans and revise plans as indicated.
Maintain comprehensive medical record documentation in required information systems and databases, following documentation and billing guidelines.
Use electronic health record activities and reporting tools to manage preventive care and proactively reach patients most in need of care.
Manage care for high-risk patients using electronic medical record outreach tools, including assessments, patient goals, and health maintenance.
Assist in developing workflows that ensure patient care needs are met.
Collaborate with providers, patients, families, and health care teams across care settings and the community.
Foster a team approach and include patients and families as active team members.
Lead efforts to ensure continuity of care beyond clinic boundaries.
Serve as liaison to acute care hospitals, specialists, post-acute care services, and community agencies.
Follow up with patients and families when patients transition between care settings.
Complete timely post-hospital follow-up, including reviewing discharge instructions, providing condition-specific education, coordinating care, and helping address barriers.
Identify targeted, rising-risk, and high-risk populations using provider referrals, risk stratification, registries, and patient lists.
Assess patients' and families' health care, educational, and psychosocial needs using standardized tools such as nurse case management assessments and health risk assessments.
Develop individualized patient and family education plans and provide instruction and counseling about illnesses, treatments, medications, and care coordination.
Provide patient self-management support that empowers patients and families to build self-care capacity and integrate health promotion into their lifestyles.
Work with clinic and leadership teams to evaluate processes, identify problems, and propose or develop process-improvement strategies.