RN - Case Management

Carle Health•Champaign, IL

12d•Hybrid

About The Position

The Outpatient Care Management AMS RN provides comprehensive protocol-based management of Warfarin for patients enrolled in Carle Health Anticoagulation Management Services. This RN will also assist in care coordination around patient's chronic diseases, coordinate and facilitate medication management, and effectively manage care transitions across the continuum once patient has been enrolled in Carle AMS. The Outpatient Care Management AMS RN will create a longitudinal, personalized care plan for each unique patient. Promoting effective partnerships between patients, families, nurses, physicians, and all other health care disciplines across the continuum.

Requirements

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
College Diploma: Nursing (Required)
Nursing 3+ years

Responsibilities

Communication and coordination between care settings across the healthcare continuum.
Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships with patients, families and all other members of the care team.
Provide education on medication adherence, follow up appointments, and other activities to maximize patient knowledge of self-care and reduce avoidable readmissions.
Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
Conduct holistic health care assessment including health risk assessment, patient preference and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity and social determinants of health.
Ensure accurate documentation of clinical, financial, and other information using appropriate systems.
Reviews and manages INR results and warfarin dosing per protocol and/or per orders from AMS Provider/Pharmacist.
Respond to patient telephone messages, including triage, education, and care coordination.
Documents within patient Electronic Medical Record (EMR) to support departmental specific workflows to ensure accuracy in care planning efforts.
Provide patient education and support for anticoagulation therapy through utilization of AMS nursing protocols and through collaboration with the AMS provider/pharmacist.