Case Manager

Northeastern Rural Health Clinics•Susanville, CA

About The Position

Case Manager Position Summary: The Case Manager’s main objective is to act as a liaison between patients, their families, and Northeastern staff members to ensure efficient and prompt health care services. They devise care plans, which include patient referrals, medication doses, treatments, evaluation of results, patient’s health goals, and a summation of the plan’s effectiveness. In some instances, case managers control health care resources, and they may also provide emotional support and will be responsible for the prompt and effective provision of health care services. Case management is defined as those activities related to tracking health outcomes and prevention activities for patients who require additional health maintenance supervision. The Case Manager is responsible for the documentation and reporting of interventions required by either funding sources or providers. The Case manager will participate in quality improvement activities and in the provider panel, meeting with the provider team weekly.

Requirements

LVN licensure with prior case management experience or other professional with 5 Years of case management experience required.
Ability to plan, organize, and coordinate care plans
Ability to multitask and prioritize duties with constantly changing urgencies
Proficient with EHR systems, Microsoft Office Suite, and other web-based programs
Critical thinking and solution-based problem-solving skills necessary to support patient's needs

Nice To Haves

Case Management Certification preferred

Responsibilities

Perform all activities outlined in the program description.
Will use Internet access for reporting to outside entities as needed.
Build and maintain generic databases for NRHC patients with special needs, such as oxygen, additional health screening needs, and anti-coagulated patients.
Independently follow policies and procedures to effect outcomes in line with grant/program designs.
Work with the Quality Improvement Department to improve the Case Management Program at NRHC.
Maintain proper documentation of activities related to health maintenance efforts.
Upon provider request, make notifications to clients when diagnostic or routine tests are outside of the expected range.
Work with scheduling and referrals to arrange follow-up.
Generates lists of patients who need chronic care management services and uses the lists to remind patients of at least three chronic care services needed. Examples include diabetes care, CAD care, lab values outside normal range and post-hospital FU appointments. Examples for children include services related to chronic conditions such as asthma, ADHD, ADD, obesity, and depression.
Generate lists of patients who may have been overlooked and who have not been seen recently. This can include pts overdue on a periodic physical exam or care management for follow-up visits.
Generate lists of patients on specific medications; the list may include managing patients who were prescribed medications with potentially harmful side effects.
Work with medical assistants, nurses, the Medical Director, and providers to identify complex or high-risk patients. Examples of such patients are those with a high level of resource use (visits, medications, and treatment), frequent visits to urgent or emergent care, frequent hospitalization, multiple co-morbidities including mental health, noncompliance with medications/treatments etc.
Help identify patients/families that might benefit from additional care management support (such as diabetic education or additional case management support).
Follow up with patients/families who have not kept important appointments.
Help coordinate treatment for mental health and substance abuse disorders.
Help organize efforts for health education programs (such as group classes and peer support).
Helps mediate any stop gaps in allowing patients to receive care such as difficulty with referral or transportation barriers for patients.
Contact patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit.
Participate in those outreach activities that target care gaps.
Be available to travel to conferences or learning opportunities as identified by the Director of Nursing, Quality, and Risk Management or grant requirements.
Maintain a professional/caring attitude toward staff and clients.
Maintain patient confidentiality at all times.
Perform other duties as assigned by the Director of Nursing, Quality, and Risk Management and the RN Case Manager, demonstrating flexibility and willingness to do extra work as needed, on an intermittent basis.