Case Manager - Care Management

Legacy Health • Portland, OR

1d

About The Position

The Case Manager coordinates and facilitates comprehensive, patient-centered, quality health care for patients with acute and chronic health conditions across the continuum of care. The role supports optimal health care outcomes within accepted standards of care and serves as an expert resource to the healthcare team on care transitions, resource use, best-practice protocols, team-based care, quality improvement, and regulatory requirements.

The Case Manager works with patients and families to identify health care issues and barriers to self-care, set priorities, and engage in appropriate interventions. The role uses culturally agile, health-literate education to support self-management, monitors outcomes through rapid quality improvement cycles, and coordinates care that is appropriate and fiscally sound.

Requirements

• Minimum of 2 years of clinical nursing experience.
• Extensive knowledge of disease management, including diagnostics, treatment and prognosis, community resources, and health care reimbursement.
• Knowledge of levels of care across the health care continuum, including inpatient, emergency care, rehabilitation, home health, hospice, long-term acute care, SNF, ICF, and ALF, and an overall understanding of utilization and resource management.
• Working knowledge of care management models across the continuum.
• Knowledge of the six core components of case management: psychosocial aspects, health care reimbursement, rehabilitation, health care management and delivery, principles of practice (including CMS guidelines and InterQual criteria), and case management concepts.
• Excellent organizational skills.
• Health-literate oral and written communication skills for effective interaction with all members of the patient's health care team.
• Knowledge of transitional planning to and from all care venues.
• Ability to determine and access appropriate community resources.
• Ability to engage patients and families in discussions of health care goals and decisions, considering cultural and health literacy implications.
• Ability to adhere to and implement regulations effectively and serve as a resource to team members regarding regulatory issues.
• Keyboard skills and ability to navigate electronic systems applicable to job functions.
• Current applicable state RN licensure.
• BLS for Healthcare Providers from the American Heart Association is required for employees performing this job in Oregon.

Nice To Haves

• Academic degree in nursing (BSN or higher).
• Relevant experience in one or more of the following: coordination of community resources, care management of diverse patient populations, or ambulatory care.
• Case management certification.

Responsibilities

• Coordinate and facilitate interdisciplinary, comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions.
• Foster optimal health care outcomes within accepted standards of care.
• Serve as an expert resource to the healthcare team regarding the continuum of care, efficient resource use, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements.
• Ensure smooth transitions of care between health care environments through planned handoffs.
• Partner with patients and families to identify health care issues and barriers to self-care, set priorities, and engage in appropriate interventions.
• Demonstrate cultural agility and use health literacy guidelines to educate patients about self-management strategies.
• Use rapid quality improvement cycles to monitor, evaluate, measure, and report progress of interventions and outcomes.
• Pace cases to ensure appropriate and fiscally sound care coordination across the continuum.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed