AK - RN Case Manager - Juneau

Centstone HC•Juneau, AK

3d•Onsite

About The Position

This position functions within the nursing department and is responsible for coordinating the delivery of appropriate and timely care for patients, promoting quality and cost-effective health care outcomes. The RN Case Manager is responsible for the active management of SEARHC patients. They collaborate with the medical provider and all interdisciplinary team members to establish individualized medical goals that maximize patient healthcare outcomes. This role coordinates multi-disciplinary care conferences for high risk or complex patients who are referred into the case management process. The Case Manager manages panel acute and chronic care needs as well as health maintenance, by continuously reviewing EHR reminders and triggers and providing outreach and education to patients. They participate in case management reviews where all high need patients are reviewed with a multi-disciplinary team of providers. The RN Case Manager works with the multi-disciplinary team as an advocate for the patient/client family at the service –delivery level, fostering patient/family decision making, independence, self-care and growth and development. They use problem-solving and anticipatory skills in meeting the needs of the patient and the provider, ensuring patient needs are addressed in a prompt, efficient manner. The role facilitates the coordination of patient referrals within SEARHC and to other outside facilities, tracking the progress of referrals and outcomes of care, and providing periodic status reports to providers on outstanding referrals. The RN Case Manager serves as the primary link for other case managers and discharge coordinators in care coordination for the patients, ensuring referral records have been received and are available for provider’s review. They proactively identify delays and obstacles to care and work to remedy individual cases and to improve the process. Additionally, the RN performs staff nursing duties in the various nursing roles in the clinic, including assessment, documentation, education, and administering appropriate medications and/or therapies. They maintain annual competencies including safety and infection control requirements, and perform duties as assigned in a responsible, respectful, and caring manner to promote effective nursing staff relationships. The role also involves maintaining a clean and safe working environment, including adequate supplies and upkeep of unit and equipment, reporting any defective or missing equipment and safety hazards, and adhering to infection control policy and procedures. The RN Case Manager works collaboratively by building bridges and creating rapport with team members within departments and across the organization, participating in department and clinic team and improvement efforts. They are an active member of the clinical team and a leader amongst the pod, nursing staff, and unit coordinators, participating in the continued development of the case management role in primary care. As an RN, they are responsible for participating in the triage role and responding to emergency situations. Performs other duties as assigned, including special projects deemed necessary to provide comprehensive health services. The role also has additional focus areas including Specialty Clinic Case Management, OB Case Management, Video Teleconferencing (VTC) coordination, and Exercise Treadmill Test (ETT) coordination.

Requirements

Graduate of an accredited school of nursing.
Current full, unrestricted Registered Nursing license in Alaska or other U.S. state required. Direct Hire must have applied for an Alaska nursing license before start date. Agency staff must have an active Alaska license.
Basic Life Support certification.
High school diploma or equivalent required.
At least 1 year of general nursing experience with at least 6 months’ employment as a clinical nurse at a SEARHC outpatient clinic OR at least 2 years of general nursing experience with a minimum of 1 year in an ambulatory setting or 1 year case management experience.
Knowledge of SEARHC services and those of other tribal health organizations in Alaska.
Understanding of the nursing process and its application in the working environment.
Knowledge of customer service principles.
Knowledge of safety and infection control principles.
Skills in assessment, anticipation of needs, and data collection.
Proficiency in the use of equipment such as computers and medical equipment.
Strong oral and written communication skills.
Ability to multi-task and work independently in a fast-paced environment.
Ability to maintain compliance with annual competencies.
Problem-solving and conflict resolution skills.
Ability to anticipate needs of others and seek help when appropriate.
Ability to work within a very fast-paced clinical setting.
Ability to move at a quick pace, stand for long periods of time, bend, stoop, climb, and move to the floor.
Ability to follow simple and complex directions and perform multiple tasks at once.
Ability to perform job using theory-based nursing practice model, evidence-based practices, and shared governance in a multi-disciplinary setting.
Must lift and/or move 50 lbs.

Nice To Haves

Bachelor’s degree preferred.
National Case Management certification preferred.
Clinical Competency required within 3 months of hire and every three years.

Responsibilities

Coordinate the delivery of appropriate and timely care for patients, promoting quality and cost-effective health care outcomes.
Actively manage SEARHC patients.
Collaborate with medical providers and interdisciplinary team members to establish individualized medical goals.
Coordinate multi-disciplinary care conferences for high-risk or complex patients.
Manage panel acute and chronic care needs, and health maintenance through EHR reminders and triggers.
Provide outreach and education to patients.
Participate in case management reviews with a multi-disciplinary team.
Act as an advocate for the patient/client family, fostering patient/family decision making, independence, self-care, and growth.
Use problem-solving and anticipatory skills to meet patient and provider needs.
Facilitate the coordination of patient referrals within SEARHC and to outside facilities.
Track referral progress and outcomes, providing status reports to providers.
Serve as the primary link for other case managers and discharge coordinators.
Ensure referral records are received and available for provider review.
Identify and remedy delays and obstacles to care.
Perform staff nursing duties including assessment, documentation, education, and medication administration.
Maintain annual competencies, including safety and infection control.
Maintain a clean and safe working environment.
Adhere to infection control policies and procedures.
Build rapport and collaborate with team members within and across departments.
Participate in department and clinic team and improvement efforts.
Act as a leader amongst the pod, nursing staff, and unit coordinators.
Participate in the continued development of the case management role in primary care.
Participate in the triage role and respond to emergency situations.
Coordinate specialty clinic referrals, manage waitlists, and review referrals for appropriateness.
Schedule patients in requested clinics based on priority systems.
Ensure pre-appointment diagnostics are ordered, scheduled, and completed.
Coordinate various clinics with other facilities.
Provide clinical support for specialty clinics, including assessment, documentation, education, and medication administration.
Prepare clinical space for selected clinics and assist providers during medical procedures.
Assist with educational in-services provided by specialty clinic providers.
Serve as the primary case manager for OB patients, responsible for intake, tracking, education, and outreach.
Work closely with primary care providers and case managers for comprehensive OB patient care.
Track postpartum care and newborn immunizations.
Coordinate video teleconferencing visits with Specialty providers from AK Native Medical Center.
Manage referrals and coordinate appointment times for Exercise Treadmill tests (Juneau).