RN CASE MANAGER (PART-TIME)

MAJOR DUTIES AND RESPONSIBILITIES

1. Responsible for serving as RN case manager for patients with chronic illness and/or conditions. Duties to include but are not limited to: maintaining an accurate record, coordinating care/follow up, and provide patient education.
2. Collaborate proactively with all team members and with a patient-focus to facilitate and maximize patient healthcare outcomes.
3. Consistently model appropriate behaviors, attitudes and skills that support the C.L.E.A.R. and H.E.A.R.T. customer-service standards to build positive relationships with patients and KTFHS employees.
4. Coordinate multi-disciplinary patient care conference for high risk or complex patients.
5. Advocate for the patient/family at the service delivery level and at the policymaking level fostering the patient/family’s decision-making, independence, and growth and development.
6. Promote health care outcomes with currently accepted clinical practice guidelines. Provide patient education, advice and information on health assessment, disease processes, medications and treatment.
7. Utilize best practice model to identify, incorporate or develop best practices for panel management. Collaborate with other teams to share and establish best practice for clinic.
8. Assist with the development and review of medical clinic and nursing related policies and procedures in accordance with evidenced based practice, federal and state regulations, and/or accreditation standards.
9. Manage panel acute care and chronic care needs as well as health maintenance, meeting clinic expectation for health maintenance standards.
10. Develop, implement, and evaluate patient care plans.
11. Use electronic health record and/or develop a tracking system to track, monitor and assure the appropriate follow-up of patients. Utilize electronic health record for ordering, scheduling and tracking patient care.
12. Handle referrals in conjunction with provider, medical assistant, and Referral Clerk.
13. Acts as a resource to the clinic. Coach and mentor all clinical team members to build or enhance capability and competency.
14. Respond to emergency situations.
15. Manage Nurse Clinic during provider’s Walk-in schedule. Duties include telephone and clinic triage for walk-in patients. Conduct initial health assessment and identify chief complaint. Nurses will coordinate with medical provider patient needs.
16. Initiate needed therapeutic measures and other general nursing care. Assist the provider as needed.

17. Participate in department and KTHFS committees as assigned.
18. Active member of clinical team, contributing to overall team function, team building and enhancement.
19. Participate in the continued development of the role of case management in the Patient Center Medical Home model. Active member of the Integrated Care Team by mentoring Integrated Care Team Medical Assistants to improve skill sets.
20. Maintain accurate, complete, timely and professional documentation in health records. Documentation of all patient contacts required; including but not limited to telephone calls, nursing visits and/or any significant changes for provider to review.
21. Provide support to the Community Health Nursing Program when appropriate; based on organizational need and supervisor direction.
22. Assist in the development and implementation of the KTHFS Quality Improvement Program, as assigned. Apply knowledge and experience with preparation for regulatory and/or accreditation review or inspections.
23. Train nursing students, family practice residents, pharmacy students, medical students, and/or any other students in outpatient clinic nursing standards and quality of care, as assigned.
24. Assist with the accurate data entry, tracking and reporting of all statistics for federal, state, I.H.S. and/or grant requirements, including but not limited to immunization reports, GPRA, IHS reports, and meaningful use; as assigned.
25. Assist with maintaining accurate records and/or administering healthcare worker required immunizations, TB testing, and certifications (ex: CPR or ACLS) for KTHFS employees, as assigned.
26. The incumbent will be called upon to accomplish other tasks within his or her scope of work.