Improve patient care for high risk and special populations through effective utilization and monitoring of healthcare resources. Work collaboratively with the NFMC care team and local, regional, state, and national healthcare resources to coordinate care and services.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Ensure coordination of medical care delivery processes, including alternate healthcare settings and the home environment, for the purposes of enhancing the patient’s health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care.
- Proactively identify and evaluate patients and families for case management from a variety of sources including referrals, providers, NFMC staff, and external sources as appropriate.
- Conduct systematic, on-going, thorough collection of information regarding patient’s physical, emotional, psychological, social, and medical status as well as other relevant sources, including professional and non-professional caregivers, medical records, direct patient contract, and family interviews.
- Collaborate in a timely manner with the patient, family/caregiver, primary provider, and other members of the health care team for developing an effective plan of care.
- Develop, in collaboration with the health care team, an appropriate, patient-specific plan of care to include short and long term goals, objectives, and actions, and coordinate, collaborate, and obtain approval of the plan among the patient, family/caregiver, primary provider, and other members of the healthcare team.
- Continuously assess achievement of established plan of care for patients.
- Maintain communication with the provider and patient regarding the care treatment plan.
- Guide the patient and family/caregiver through the healthcare system, maximizing use of resources.
- Coordinate and execute the plan of care, optimizing access to appropriate services.
- Provide guidance to the LPN Case Managers in the development, modification, and implementation of the care plan.
- Identify, develop, and utilize a variety of community resources to optimize access to services and medical care based upon the changing requirements of payer source. Ensure timely and appropriate provision of services.
- Ensure that necessary referrals are ordered and scheduled appropriately.
- Track referrals to assure timely and appropriate provision of services and receipt of results.
- Support the patient and family/caregiver to ensure risk reduction, behavior modification, and treatment adherence education is received as appropriate.
- Serve as an advocate for the patient and family/caregiver as required
- Stay informed of changes in third party healthcare coverage benefits and requirements.
- Complete medical record documentation, data collection, and tracking reports.
- Submit reports as requested by NFMC team members.
- Coordinate individual or group based education, counseling, or patient self-management goal setting as appropriate.
- Coordinate and participate in interdisciplinary team meetings, designated facility meetings, and care coordination meetings.
- Share knowledge and experiences gained from own clinical experience and education relevant to case management.
- Monitor and evaluate patient outcome and adherence to the treatment plan.
- Conduct and/or participate in program evaluation as directed.
- Coordinate appointments to ensure continuing care for the patient to encourage patient to seek appropriate care.
- Maintain strictest confidentiality as appropriate.
- Perform all other duties as assigned by management in a professional and efficient manner.
- Other duties as assigned.
EDUCATION AND/OR EXPERIENCE:
- Currently licensed RN
- 3 years experience in clinical nursing or 3 years experience in medical case management of which 18 months is healthcare discharge planning or clinical case management for adults, children, families, seniors, or groups.
- Electronic medical records experience, desirable
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Human Resources Phone: (850) 385-4494 – Fax: (850) 298-6054
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