Using principles of Patient Centered Medical Home (PCMH), the Registered Nurse Case Manager (RN) will demonstrate professional nursing practice, excellent communication and critical thinking skills, self-management expertise along with outstanding customer service to promote and assist individuals to manage their health through chronic disease management, wellness promotion and early detection. The RN Case Manager will assist in coordination and integration of medical and behavioral health by working with the patient as well as various Whitney Young Health (WYH) staff to achieve an effective continuity of care.
Age Specific Criteria
RN Case Manager demonstrates knowledge, skills and abilities to provide care to the age groups served (birth and above).
Demonstrates knowledge of normal growth and development.
Interpret age-specific responses to treatment.
Demonstrates knowledge of age-specific safety precautions.
Utilize evidence based practice standards, PCMH guidelines, knowledge of Chronic Illness, thus identifying patient with chronic conditions for coordination of care for high risk patients.
Collaborate with providers/clinical teams to identify target patient population for care coordination based on Athena/Relevant reports, lab/diagnosis criteria, and individual recommendations.
Collaborate with care team regarding patient plan of care issues, testing or specialty referrals that require the RN Case Manager to assist/follow patient in navigating complex health systems.
Coordinate process for outreach to patients with care opportunities to ensure no gaps to care.
Initiate a Transition of Care follow up phone calls for hospital/ER discharge and schedule patient to see primary care provider. RN Case Manager will follow and develop a patient engaged plan of care for all high risk patients with chronic conditions that pose a risk for readmission to hospital or ED.
Collaborate with on-sight pharmacist to see patients for Transition of Care (Hospital discharge/ED); to provide medication reconciliation and educate patient to medication use/side effects.
Initiate pre-visit/post visit planning, anticipate the coordination needs of the patient panel, and delegate the task of obtaining necessary documentation, lab tests, consult reports and hospital/ER discharge papers prior to patient visits
Evaluate patient visit lists at least a week prior to day of appointment to begin care coordination/care management. Consider need to meet with patient at time of appointment (in-person) or via phone to engage patient to a patient engaged plan of care accompanied with patient specific goals. RN Case Manager ensures patients are provided a copy of their plan of care (documents such).
Refer patient to appropriate education and maintenance care: Health Coach, Nutrition. Assist patient to schedule specialty referrals/follow up on all prior auth. Completion so as to not delay care. Assess Social Determinants of Health (SDOH) needs and refers patient to the Unite Us Platform (Referral Center) in meeting patient needs for positive outcomes.
Educate/engage patients to evidence based self-managed, chronic disease management they can undertake to gain greater control of their health status to improve health outcomes that support a healthy life style. (consider patients desired learning style when providing education).
Utilize technology to assist with all aspects of care: EMR documentation, disease registry, HIXNY, Unite Us Referral Platform.
Collaborate with pre/post visit planners, Behavioral Health, Health Home Services as it relates to patient engaged in Care Management, with active participation in monthly care team meetings. Update care plan as warranted by collaborative team discussion.
Adheres to CMS guidelines as it relates to care coordination, care plan management: ensuring patient has a copy of patient engaged care plan and goals, along with patient education and appropriate documentation of such.
Ensures patient care safety thus utilizing Adult Protective Services and or Child Protective Services to assist in ensuring patient safety. RN Case Managers will ensure compliance with local, state DOH, and federal regulations (OSHA, NCQA, NYSDOH, HRSA, CMS)
Emergent Needs: assist team with patient care activities (initial check in/room patients, perform nursing assessment, triage patients, obtain vital signs, assist Providers with office visit needs.
Consistently follows established protocols, clinical guidelines and infection control guidelines with any patient interaction.
Consistently identifies patient/family educational/learning needs regarding illness/care. Institutes cultural respect to engage patient to patient engaged care plan/goals for positive health outcomes.
Assists with orientation of new employees.
Communicates to patients in an age-appropriate manner.
Cognizant of language needs/health literacy levels for patient teaching.
Recognizes and communicates changes in patient condition to providers in a timely manner.
Participates in daily team huddle for effective team communication in planning as it relates to the clinic workflow.
Participates in quality improvement committee to improve patient outcomes and gaps to care.
Demonstrates knowledge of current immunization/preventative care needs and practices.
Chronic Care Management: RN Case Manager identifies qualified patient with (Chronic Disease), engaging with the patient in a patient engaged plan of care via telephone or in-person visits.
The RN Case Manager adheres to CMS guidelines to ensure plan of care/goals are updated with each encounter. The Case Manager adds the time spent with the patient to the patient record, closing chart at the end of a 30-day period for billing.
Maintains accurate documentation related to care coordination for pulling collective data.
Accurately collects and documents clinical data and other data as required (i.e. clinical and referral logs, quality control documents).
Consistently utilizes available resources to validate information and/or assessments when needed.
Consistently utilizes documentation as a tool of communication.
Documentation accurately reflects nursing assessments, interventions, treatments and medications.
Accurately completes charting, referral, lab and other forms.
Performs accurate basic physical assessments.
Collaborates with multidisciplinary team to identify patient needs and closes the loop to prevent gaps to care.
Demonstrates acceptable technical skills in providing patient care.
Administers medications safely in accordance with relevant policies.
Demonstrates initiative and flexibility with assignments.
Assists, as needed, with clinic workflow and procedural needs.
Considers patient age, disabilities, language and cultural needs and special needs with all care rendered
Demonstrates excellence in both internal and external customer service, along with patient engagement.
Understands and is able to effectively communicate HIPAA compliance, corporate compliance and client confidentiality.
Ensures and/or remains in compliance with local, state, and federal regulation (FQHC), i.e. DHHS HRSA, CMS guidelines, and NYSDOH (article 28), and all accreditation standards (e.g. Joint Commission and NCQA-PCMH).
Adheres to the National Patient Safety Goals as defined by the Joint Commission/NCQA and Whitney M. Young Jr. Health Center.
Completes other duties as assigned such as continued education.
Bachelor's degree in Nursing /graduate of a registered approval program for Registered Professional Nurses with current NYS registration. Three (3) years' experience in a health care setting. Demonstrated excellent customer service, good communication, and interpersonal skills. Beginner to intermediate proficiency with computer use.
Two (2) years' experience working with patients with chronic conditions or care coordination in a medical setting. Commission for Case Manager (CCM) certification. Flexibility to adjust to schedule changes. Training in laboratory/phlebotomy techniques. Knowledge of managed care requirements. Bilingual.
Please be aware that as a facility regulated under Article 28 of the New York State Public Health Law, COVID-19 vaccination is a requirement of employment. Whitney Young Health also requires the COVID-19 booster.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status.