RN Case Manager Outpatient - Acworth
Company: Wellstar Health System
Location: Acworth
Posted on: October 3, 2024
Job Description:
Facility: Acworth Health ParkJob SummaryAs a member of the
Population Health Management (PHM) Team, the Outpatient Case
Manager works with members, providers and caregivers to provide
intensive, comprehensive case management and increase efficient
utilization of services for patient with complex needs; identifies
chronic, complex and or catastrophic cases through the case
management process and or referrals and initiates intensive case
management according to program guidelines. This role will utilize
multiple disciplines as CM to focus on various different patient
populations.The goal of the PHM OP Case Manager is to effectively
manage patients on an outpatient basis and during episodes of acute
hospitalizations (in conjunction with their inpatient counterparts)
to assure the appropriate level-of-care is provided, optimize safe
transition to home or the next level of care, prevent inpatient
re-admissions and ensure that the patients' medical, environmental
and psychosocial needs are met over the continuum of care. The Case
Manager acts as an advocate for members and their families linking
them to other appropriate disciplines on the care team to
facilitate patient/family education for better self-management,
navigation of the health care system, and to identify community
resources as necessary.The PHM OP Case Manager
- Will be embedded and connect with patients face to face or on
the phone
- Telephonic onlyBoth types will coordinate with other members of
the PHM team or multidisciplinary care team to adequately
coordinate and manage patient needsTelephonic Case Management
FocusWill have a role that primarily the same as the outpatient PHM
OP case manager, but will follow patient telephonically only and
will support more multiple physician practices or patient
populations based on patient volumes.Core Responsibilities And
Essential FunctionsAssessment
- Reviews all patient referrals to determine criteria met for
case management.
- Performs comprehensive assessment to identify patient/family
needs.
- Identify all high risk areas, including medical, environmental
and psychosocial areas
- Reviews all options/resources available to meet client/family
needs and to promote optimum health and the most cost effective
manner. 20% Planning
- Collaborates with the patient/family, physician and
Multidisciplinary team in the formation and modification of a
comprehensive and individualized plan of care which addresses the
needs and goals of identified high-risk patients with complex
chronic conditions.
- Integrates evidence-based clinical guidelines, preventive
health guidelines, protocols, and other identified risk information
in the development of plans of care that are patient-centric,
promoting quality and efficiency in the delivery of healthcare for
high risk population.
- Develops and/or utilizes processes that monitor patients across
the health continuum with a focus on effective and safe transitions
from hospital to home, nursing home or rehab facility with goal of
optimizing resources and reduction of avoidable acute care
readmissions. 20% Implementation
- Matches the patient/family needs to available and appropriate
resources to carry out the plan of care. Utilizes telephonic and
face-to-face communication as appropriate to engage with and to
meet needs of patients.
- Prioritizes and collaborates with patients/families/healthcare
providers regularly to optimize patient engagement and clinical
outcomes in the most efficient manner.
- Coordinate patient care services necessary to meet patient
needs. Makes appropriate referral to other team members to assist
with resource needs.
- A strong emphasis is placed on Wellness, Disease Management and
patient education to ensure compliance with the plan of care and
prevention of complications with various ailments and chronic
conditions.
- Identify care gaps and works with team to close the gaps
- They will coordinate member visits with primary care providers
and specialists as needed. 40% Monitoring/Evaluation
- Monitors care through data collection and analysis. Evaluates
processes utilizing a systematic approach to determine the
effectiveness of the case management plan in terms of reaching
desired outcomes and goals to improve the quality, access and cost
of care.
- Manages performance feedback metrics to further refine the care
model to maximize clinical, quality, and fiscal outcomes for the
targeted population.
- Participates in team meetings to evaluate current processes,
provide and receive feedback, review specific cases with goal of
problem-solving for improved patient adherence to plan of care,
clinical outcomes and patient/provider satisfaction. 20%Required
Minimum EducationGraduate of accredited school of nursing with a
current Georgia RN license. Required andBachelor's Degree In
Nursing PreferredRequired Minimum License(s) and
Certification(s):All Certifications Are Required Upon Hire Unless
Otherwise Stated.
- Reg Nurse (Single State) or RN - Multi-state Compact
- Basic Life Support or BLS - InstructorAdditional License(s) And
Certification(s)Required Minimum Experience:Minimum 5 Years In
Clinical Experience RequiredPrevious Case Management experienceCase
Manager Certification (CCM) Preferred AndComputer experience with
Microsoft office suite and electronic health records Preferred
andExperience in data collection and analysis and basic research
techniques desired. PreferredRequired Minimum SkillsKnowledge of
complex case management role and processes.Demonstrates customer
focused interpersonal skills to effectively interact with
practitioners, multidisciplinary health care team, community
agencies, patients and families with diverse backgrounds, values,
and religious/cultural ideals.Outgoing and autonomous, flexible
personality that can engage the geriatric population over the
phoneand support the development of PHM CM role..Demonstrates
leadership qualities including excellent organizational and time
management skills, verbal and written communication skills,
problem-solving, decision-making, priority setting, and work
delegation.Ability to utilize risk-stratification screening
criteria, review clinical data in identifying patient/client health
care needs.
Keywords: Wellstar Health System, Redan , RN Case Manager Outpatient - Acworth, Executive , Acworth, Georgia
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