RN Case Manager

The RN Case Manager works with the clinical department and acts as a liaison between our physician practices and their patients. The The RN Case Manager advocates for personalized treatment options that address a patient’s unique care needs. The RN Case Manager uses a patient-centric approach that supports the value-based care model, offers education and guidance for navigating complex medical decisions, and coordinates care for patients when they need support the most, including post discharge and when social needs are not met. The RN Case Manager will support special clinical programs and initiatives to support VBC and shared savings goals.

You will be responsible for using your assessment and communication skills to engage with patients in need of clinical support to determine and prioritize their needs. You will deliver patient-centered care, provide exceptional customer service, and work within your scope of practice to provide evidence-based education, assessment, and care navigation Identify patient/caregiver education needs through telephonic assessment/engagement and ensure that patient/caregiver have adequate information to participate in the successful transition back to their home setting from an inpatient or post-acute facility stay Conduct timely telephonic clinical outreach to identified patients  Collaborate with PCP, NP, and other members of the healthcare team to coordinate care for patients and actively help keep them stable at home Serve as the point of contact and informational resource for patients, care team, family/caregiver(s), payers, and community resources. Implement interventions that improve health outcomes, lower costs, and improve the experience for the patient. Work collaboratively with provider offices, SNFs, hospitals, and other teams in Clinical Services to support each patient’s needs most efficiently and effectively. Assist in the coordination across the continuum of care while maintaining confidentiality. Guide patients through the health care system and help them overcome barriers. Coordinate treatment and services for patients  Schedule medical appointments as needed  Communicate about a patient’s health condition with the patient and their family  Provides community resources to patients as needed and to support resolution of SDoH Maintain a comprehensive working knowledge of community resources. Assume accountability for the quality of care. Continually seek new knowledge and learning that supports clinical care coordination. Support non-RN team members in their contributions to care coordination by educating and providing clinical guidance as needed May be asked to support the Director in day-to-day supervision of team members as needed.