Nurse Case Manager

Job Requirements

General Summary

Under supervision of the Case Management Leadership, will manage and oversee the comprehensive assessment, planning, implementation, monitoring, and overall evaluation of individual patient needs. A Case Manager assists in identifying appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. A Case Manager will provide care management and coordination of care for patients across various diseases. A Case Manager will focus on achieving patient wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. Overall, the Case Manager will promote direct communication with the patient, and appropriate service personnel, in order to optimize outcomes.

Principal Responsibilities And Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Demonstrate critical thinking skills when utilizing the nursing process, based on research, evidence-based outcomes and Standards of Practice to meet patient’s health care needs.
• Gathers and analyzes specific criteria and guidelines to track inpatient admissions in and out-of-network, ED, readmission and high cost utilization of members associated with UMQCN/UMMS/UMBMC/UMBWMG providers.
• Create population-based management strategies and processes (based on a solid understanding of care management, including disease management and preventive care) that help patients manage their healthcare needs and foster care quality, cost-effectiveness, and patient engagement.
• Identify patients who may benefit from telephonic outreach or coordination of care; initiate the care-management processes in a quality focused, cost-effective manner across the continuum of care.
• Assists the Primary Care Physician to ensure the client's medical needs are met in the most efficient, cost- effective manner.
• Reach out to patients assigned by his or her supervisor to assess their most urgent needs, appraise the situation, and listen to the patients’ concerns
• Establish collaborative partnerships with patients to assist them in examining patterns of health care needs, decisions, lifestyle choices, and utilization of resources that affect their health.
• Advocate, educate and coach patients, the family and/or caregiver about treatment options, community resources, and psycho-social concerns in order to set goals and help the client develop self-care skills and independence appropriate to their age and developmental level. Implement Case Management interventions with the goal to optimize the patient’s health status
• Facilitate communication and coordination between members of the health care delivery team, involving the client in the decision-making process in order to minimize fragmentation in services.
• Document appropriately in patient medical records and/or care management application
• Coordinates community resources with emphasis on medical, behavioral and social services. Applies case management standards and maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues. Tracks, evaluates, and provides oversight for transitions of care, synchronizing “warm handoffs” between the clinic and hospitals, emergency departments or care facilities. Facilitates and ensures the sharing of information across people, functions, and sites.
• Work collaboratively with physicians and clinical and administrative leadership to design and implement case/disease-management protocols
• Manages active cases based on case intensity and acuity, per departmental standards. Specialty Case Manager caseloads may vary.
• Recognizes/understands responsibility of this key role and the responsibility this position demands in direct support of high quality patient care delivery regardless of assignment. This will be measured by the accountability/initiative taken in the performance of daily duties and assignments as itemized in major accountabilities section of job description.
• Establish collaborative partnerships with patients to assist them in examining patterns of health care needs, decisions, lifestyle choices, and utilization of resources that affect their health.
• Be attentive to detail to maintain accurate and timely data exchanges among all entities involved in the patients’ care
• Consult with other external agencies to provide support services and resources
• Communicate effectively with patients, physicians, and their staff on a regular basis.
• Delegates and oversees the care management of lower-risk patients as well as routine chronic disease population management tasks to assigned caregivers.
• Participates in monthly chart audits.
• Performs special projects as assigned.
• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
• Demonstrates leadership, mentorship and teamwork within dedicated care teams including clinicians, chronic disease care coordinators, medical assistants, pharmacists, social workers and others
• Performs other duties as assigned.
  
  

Work Experience

Education and Experience

• Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required; BSN preferred.
• 3 to 5 years of care coordination experience and/or experience working in an outpatient ambulatory setting
• Experience with educating patients and patient goal setting (essential)
• Case Management Certification (preferred)
• Experience in a manage care information environment (preferred)
• Preferred experience would include knowledge of quality improvement processes (LEAN or PDSA); practice re-design work such as patient centered medical home and Joint Commission and National Committee for Quality Assurance (NCQA) accreditations.
  
  

Knowledge, Skills And Abilities

• Knowledge and experience with managing and overseeing the comprehensive assessment, planning, implementation and overall evaluation of individual patient needs
• Proficient analytical, organization, and problem-solving skills to identify opportunities, to implement efficient work processes as it relates to case management
• Proficient documentation skills to maintain client records
• Ability to work effectively in a stressful work environment and handle confidential issues with integrity and discretion
• Critical thinking skills to analyze and solve problems
• Strong problem management strategies and issue resolution skills
• Excellent interpersonal, verbal, and written communication skills
• Strong organization skills, detail oriented, and knowledgeable
• Ability to work independently and effectively in a fast pace environment.
• Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
• Ability to effectively present information and respond to questions from families, members, providers, and clients, as well as the ability to relate effectively to upper management
• Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills
• Understands benefit/payer systems and reimbursement structures for patients.
• Strong clinical knowledge of broad range of medical practice settings and healthcare delivery systems
• Thorough and solid knowledge of health care and managed care delivery systems. This includes standards of medical practice, insurance benefits structure, and the utilization and case management process.
• Knowledge of state and federal laws and resources
• Proficiency in Microsoft Office including Outlook, Word, Excel and PowerPoint; knowledge of or the ability to learn care management/EMRsoftware (e.g., Epic) and other software in order to perform job duties