Case Manager - Care Management

Legacy Health•Portland, OR
•$54 - $81

About The Position

The Case Manager coordinates and facilitates interdisciplinary, comprehensive, patient-centered, quality health care for patients with acute and chronic health conditions throughout the continuum of care. The role supports optimal health outcomes within accepted standards of care and serves as an expert resource to the healthcare team on care transitions, resource use, best practices, team-based care, quality improvement, and regulatory requirements. The Case Manager partners with patients and families to identify health care issues and barriers to self-care, set priorities, and engage in appropriate interventions. The role uses cultural agility and health literacy guidelines to educate patients about self-management strategies, monitors and reports intervention progress and outcomes, and coordinates care across settings in an appropriate and fiscally sound manner.

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 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 settings.
  • 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 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 coordination of community resources, care management of diverse patient populations, or ambulatory care.
  • Knowledge of levels of care across the health care continuum, including inpatient, emergency care, rehabilitation, home health, hospice, long-term acute care, skilled nursing facilities, intermediate care facilities, and assisted living facilities, with an overall understanding of utilization and resource management.
  • Working knowledge of care management models across the continuum.
  • Case management certification.

Responsibilities

  • Coordinate and facilitate interdisciplinary provision of 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.
  • Use cultural agility and health literacy guidelines to educate patients about self-management strategies.
  • Use rapid quality improvement cycles to monitor, evaluate, measure, and report intervention progress and outcomes.
  • Pace the case to ensure appropriate and fiscally sound care coordination across the continuum.
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