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POSITION SUMMARY

To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by functioning as part of a multidisciplinary team in an outpatient setting. The RN Care Manager acts as a patient advocate, educator, and care coordinator for a specific patient population across the continuum of care.

PRIMARY ACCOUNTABILITIES 1.

Perform reviews to assure members are receiving care in the appropriate setting at the appropriate level. 2. Complete a thorough assessment that collects in-depth information about a member's unique situation and functioning, including Social Risk Factors SDF, in order to identify individual needs. Information gathered should include direct client contact information and all other relevant sources. Based on identified needs, develop a comprehensive case management plan. 3. Develop a care management plan in conjunction with the member and the rest of the member's care team, including the PCP, specialist, and other members of the care team. 4. Implement plans by executing and documenting specific interventions, activities and/or tasks that will lead to accomplishing the established goals. 5. Provide health coaching on member/family self management skills and navigation support for the member's unique health conditions and needs. 6. Document all member interactions, assessments, care plan updates, and coordination of care interventions designed to accomplish established goals per program requirements in the care management document system. 7. Evaluate the plan at appropriate intervals to determine the effectiveness in reaching the goals and outcomes. Monitor the member's compliance with the treatment plan, and modify the plan as necessary. 8. Maintain member confidentiality and privacy, ensuring member safety, adherence to advocacy ethics as well as legal and accreditation/regulatory standards. 9. Provide education to patients, families, and significant others: act as an information resource to health care professionals, patients, and the public. 10. Evaluate member's appropriateness for referrals for other care management programs and/or community resources and services and assist with coordination of these services. 11. Participate in performance improvement activities, data collection and continuous quality improvement (CQI) activities.