Registered Nurse (Chronic Care Case Manager)

**IF YOU PREVIOUSLY APPLIED FOR THIS POSITION, YOU DO NOT NEED TO RE-SUBMIT YOUR APPLICATION**

Position Summary : Under the general supervision of the Chronic Care Case Management RN Supervisor (CCCMRNS), the Chronic Care Case Management RN will perform telephonic and disease management assessments to empower patients to better understand their illness and to self-manage their conditions. This job class is treated as FLSA Exempt.

Essential Functions : Essential functions may vary among positions and may include the following tasks, knowledge, abilities, skills and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

Tasks:

• Provides assessment, disease management, education, training, and other clinically based activities to coordinate care among providers, patients and the community • Makes adequate contact with the patients with a focus on behavioral goal setting and patient-centered support planning. Identifies patient resource needs, provides information on possible resources and referrals to patients • Collaborates with other health care providers to review actual and proposed medical care and services against established coverage guidelines review criteria • Manages network participation, care with specialty networks, care with medical providers, and transfers to alternate levels of care using knowledge of benefit plan design • Recommends services for patients using care alternatives available in the community. Identifies potentially unnecessary services and care-delivery settings and recommends alternatives by analyzing clinical protocols • Examines clinical programs information to identify members for specific case management and/or disease management activities or interventions by using established screening criteria • Conducts admission reviews, post-discharge calls, and discharge planning • Conduct thorough assessments of patients' health status, medical history, and current treatment plans to create individualized disease management plans • Educate patients and their families about their specific chronic condition, including symptoms, treatment options, and self-care practices • Monitor and evaluate patients' response to treatment, making necessary adjustments to their care plans as needed • Collaborate with other healthcare professionals, such as physicians, pharmacists, and social workers, to ensure coordinated and holistic care for patients • Provide ongoing support and counseling to patients and their families, addressing their concerns, providing emotional support, and promoting self-management techniques • Assist in organizing and conducting educational programs and workshops for patients, caregivers, and the community to raise awareness and improve disease management practices • Maintain accurate and up-to-date medical records and documentation of patient assessments, care plans, interventions, and outcomes • Stay updated with the latest research, advancements, and best practices in disease management to deliver evidence-based care • Collaborate with insurance providers and case managers to ensure proper reimbursement for services provided and facilitate smooth transitions of care • Participate in quality improvement initiatives and contribute to developing and implementing evidence-based protocols and guidelines for disease management • Multidisciplinary Care Coordination: Follows established policies, procedures and standing orders. • Follows patients through the care continuum and collaborates with other members of the health care team to ensure continuity of care and implements the agreed plan of care. • Consults with physicians and other health care providers regarding patient specific clinical, social and behavior health related issues and educational needs. • Facilitates timely and appropriate referrals and fosters positive relations with community providers and partners. • Participates in patient care conferences including but not limited to hospital, clinic, home health care, SNF/LTC, etc as well as specialty team meetings as required by Health Plans for individual groups of members and/or eligibility status (i.e Special Needs, Individual Education Plan, Disability, etc) by preparing and completing required documents. • Maintains professional knowledge and proficiency in Medical SW through continuing education, staff meetings, training and conferences, etc. • Participates in the data collection efforts to track outcomes. • Performs other job related duties as assigned to maintain and enhance departmental operations.