Case Manager - Care Management

Legacy Health • Portland, OR

1d

About The Position

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

The Case Manager partners with patients and families to identify health care concerns and barriers to self-care, establish priorities, and select appropriate interventions. The role provides education on self-management using culturally responsive approaches and health literacy guidelines, coordinates planned handoffs between care settings, and monitors intervention progress and outcomes through rapid quality improvement cycles. The Case Manager also paces care to support appropriate and fiscally sound coordination across the continuum.

Requirements

• Minimum of 2 years of clinical nursing experience.
• Extensive knowledge of disease management, including diagnostics, treatment, prognosis, community resources, and health care reimbursement.
• Knowledge of levels of care across the 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 with attention to cultural and health literacy considerations.
• Ability to adhere to and implement regulations effectively.
• 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) preferred.
• Relevant experience in one or more of the following areas preferred: coordination of community resources, care management of diverse patient populations, or ambulatory care.
• Case management certification preferred.

Responsibilities

• Coordinate and facilitate interdisciplinary, comprehensive, patient-centered care throughout the continuum for patients with acute and chronic health conditions.
• Promote optimal health care outcomes within accepted standards of care.
• Serve as a resource to the health care team on the continuum of care, efficient resource use, best-practice protocols, team-based care, quality indicators and improvement, and regulatory requirements.
• Ensure smooth transitions 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 appropriate interventions.
• Provide education on self-management strategies using cultural agility and health literacy guidelines.
• Use rapid quality improvement cycles to monitor, evaluate, measure, and report intervention progress and outcomes.
• Pace cases to ensure appropriate and fiscally sound care coordination across the continuum.
• Serve as a resource to team members regarding regulatory issues and implement applicable regulations effectively.

What This Job Offers

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