Case Manager

Essential Duties and Responsibilities

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• Assists all patients through the healthcare system by acting as a patient advocate and navigator.

•  Participates in patient-centered team meetings and quality improvement initiatives.

•  Facilitates health and disease patient education.

•  Supports patient self-management of disease and behavior modification interventions.

•  Coordinates (in conjunction with other care team members) continuity of patient care with external healthcare organizations and facilities, including the process of transitional care from hospital discharge and referrals from the primary care provider to a specialty care provider.

•  Coordinate's continuity of patient care with patients and families following hospital admission, discharge, and ER visits.

•  Helps to establish and maintain Transitional Care Management services within the Eagle View Organization and responsible for the coordination of patient care for TCM services.

•  Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for re-admission to a hospital setting.

•  Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.

•  Helps to establish and maintain the Chronic Case Management services, in coordination with the Director of Quality, within the Eagle View Organization.

•  Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

•  Facilitates patient medication management based upon standing orders and protocols.

•  Participates on a team for data collection, health outcomes reporting, and programmatic evaluation related to primary care.

•  Follows protocols and acts on standing orders per clinician guidance to assist with refills, ordering preventative/screening interventions, etc. within RN scope of practice.

•  Provides support to medical assistants and nurses regarding clinical guidelines and protocols.

•  Special projects, initiatives, and other job duties as assigned.

•  Acts as triage nurse for telephone calls.

•  Ensures that tasks in EHR inbox is completed daily in conjunction with other nursing support staff.

•  Maintains privacy of patient per HIPPA guidelines.

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Qualifications:​

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• Educational experience at a minimum

• At least two years experience preferred 

• RN/LPN: Graduation from an accredited school of nursing, including any of the following programs: Associate Degree, diploma, or bachelor's degree.

• Excellent verbal and written communication skills

• Excellent interpersonal and customer service skills

• Excellent organizational skills and attention to detail

• Excellent time management skills with a proven ability to meet deadlines

• Sensitivity to Patient Concerns

• Excellent knowledge of and ability to work with computer systems

• Must be able to work independently

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