RN Case Manager (Non-Supervisory)

Southern Indian Health Council, Inc•Alpine, CA

About The Position

The Registered Nurse Case Manager (RNCM) is responsible for delivering Care Management services to the SIHC population. This individual will manage, as directed by the Attending Provider, patientswith chronic illness, mental health issues, or life-altering conditions to gain enhanced access to ambulatory clinical or diagnostic services, inpatient acute care, post-acute SNF, LTACH or rehabilitation programs, and other medically necessary and appropriate community services. Duties include meeting with patients and their families, connecting patients with professional services, and maintaining consistent communication with patients to assess their wellbeing and liaising with facilities as needed to promote access and care. The RNCM developss treatment plans, sets the course of care and collaborates with the multidisciplinary team to suggest and make changes as needed based on patient progress or changes in condition.

Requirements

Must possess a current California Registered Nurse license.
A minimum of 3 years’ experience in a similar healthcare role.
Must have knowledge and understanding of HIPAA in the ambulatory care setting, with absolute ability to maintain confidentiality according to standards.
Must possess current CPR; ACLS must be obtained in the first four weeks of employment.
A valid driver’s license is required at the time of appointment and must be maintained throughout employment. Applicants must be insurable under SIHC vehicle insurance policy at the time of hire and throughout employment.
Certifications and/or licenses appropriate to the positions required education and profession must also be valid and maintained.
Applicants must have a reputation for honesty and trustworthiness.
Must be responsible and able to exercise good judgment, accept administrative supervision, follow detail, including the ability to interact effectively and communicate with people in a professional and courteous manner.
Must be highly confidential and work as a team with other staff.
Must exhibit cultural and community awareness and sensitivity.
Strong team building, interpersonal, and organizational skills.
Ability to establish and maintain effective peer relationships with coworkers within the Department, clinic-wide, and the public.
Must be able to express ideas clearly, concisely, address audiences effectively, and exercise balanced judgment in evaluating situations and making decisions.
Willing to be part of a team and cooperate in accomplishing department goals and objectives.
Ability to prioritize, meet deadlines, take initiative, be proactive, and function in a rapidly changing environment.
Ability to work with people of all social and ethnic backgrounds and to resolve conflicts, negotiates situations, and facilitate consensus.
Applicants must successfully pass a pre-employment physical exam, tuberculin skin test or x-ray, and blood/urine/drug screening test.
Health must be adequate to perform all duties of the position.

Responsibilities

Assessment of the patient’s physical, mental wellness, needs, preferences, financial status, and abilities. The RNCM uses this information to develop individualized care plans.
Accepts all referral for service from multiple sources including different departments, care teams, community members, patients, and/or families.
Appropriately triages referrals according to medical necessity. Must be able to accurately assess the criticality of need within 24 hours of referral. If patient needs urgent services, must be able to direct Care Coordinator and/or the Patient Advocate to coordinate care for patient in these situations.
Works collaboratively with patients, families, medical providers, nurses, Tribal entities, and all members of the multidisciplinary healthcare team to provide high quality and patient-driven care.
Collaborates and communicates with patients, families, support networks, and health care professionals to establish and implement the plan of care.
Documents patient progress in NextGen electronic health record (EHR) related to the plan of care, including charting referrals, home visits and other notable interactions.
Evaluates patient progress using nationally/local recognized guidelines at established intervals, and as needed, while collaborating with the multidisciplinary care team to adjust the plan of care to improve outcomes.
Documents intake information, reassessment information, referrals, case reports and home visits within the EHR.
Determines the need for medical, therapeutic, psycho-social, or psychiatric evaluations based on patient progress. May initiate referrals based upon IHC standardized protocols in collaboration with the medical team.
Coordinates and provides patient care based on an approved treatment plan.
Ensures that patients are active participants and decision makers in their treatment plan, answering any questions they may have.
Determines case closure by evaluating patient progress toward established goals.
Builds strong relationships with various health care discipline teams throughout the case management process.
Assists patients and families with necessary financial assistance referrals and eligibility determination.
Establishes and provides ongoing communication between SIHC and patients who would benefit from referral to community social resource agencies.
May be tasked to cover RN clinical duties, in SIHC at both clinics (Alpine and Campo) during critical staffing shortages.
Communicates care plan to chain of command as appropriate. Seeks guidance in challenging clinical situations.
Other duties as assigned.
This position may require working weekends and evenings as needed.