Nurse Case Manager Outpatient

JPS Health Network•Fort Worth, TX

36d•Onsite

About The Position

Job Summary: The Nurse Case Manager Outpatient provides guidance and direction and acts as a resource to department team members to enhance patient care. The Nurse Case Manager Outpatient is responsible for providing care management services and support to an assigned population with the purpose of improving patient health outcomes via a coordinated approach. The Nurse Case Manager Outpatient works in continuous partnership with patients and their family members, as well as clinic, hospital and post-acute partners, along with community based organizations, to achieve the desired outcomes. Using a defined process, the Nurse Case Manager Outpatient, identifies patients through risk stratification, establishes care plans and goals and coordinates care and services through the continuum of care with the goal of enhancing patient health, improving adherence to health programs and reducing health care costs. This position integrates population management, care transition, utilization and quality management functions to enhance the quality of clinical outcomes and patient satisfaction while achieving the desired financial and resource utilization outcomes

Requirements

Bachelor's Degree in Nursing from an accredited college or university.
3-5 years of clinical experience and/or care coordination and discharge planning, utilization management, case management, or other cost/quality management.
Current RN licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state.
Current CPR/BLS. Certification may be obtained subsequent to hire. Must be maintained throughout employment.
Valid Driver's License in good standing.

Nice To Haves

Master's Degree in Nursing from an accredited college or university.
Certified Case Manager (CCM) through the commission for Case Management Certification or American Case Management (ACM) certification through the American Case Management Association.

Responsibilities

In conjunction with data analytic tools, payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination including but not limited to, preventive health care, disease management, behavioral health screenings and interventions, care opportunities, etc.
Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-cost, high-need, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.
Manages and supports the assigned population with moderate to complex care needs throughout a defined episode of care.
Aids patient navigation through the care continuum with the goal of preventing and/or reducing readmissions, admissions, avoidable ED visits and ensuring that care is provided the right time, place, person and location.
Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health, dieticians and specialists in order to provide ongoing care coordination.
Provides care management services to assigned patients telephonically and face to face. Travel as needed to provider offices, hospitals, patient homes and post-acute settings may be required. Local travel may be required to perform duties at multiple sites.
Manages effective transitions in care by facilitating warm hand offs with various interdisciplinary team members, physicians and community partners.
Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
Assists patients with medication management and compliance, including a medication review, and makes referrals to other care team members such as a pharmacist to promote medication adherence.
Provides education and coaching regarding chronic disease/s, self-management, community resources, etc. to support and empower patients to take a more proactive role in managing their health, well-being and shared decision making.
Job description is not an all-inclusive list of duties and may be subject to change with or without notice. Staff are expected to perform other duties as assigned.