Incumbent serves as an Outpatient/Inpatient RN Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) as the supportive contact for specified groups of identified high risk patients; will specifically focus on specialty clinics that need specific Case Management attention. The Case Manager meets essential health, education and social needs for patients while ensuring quality, cost effective healthcare. The case manager facilitates care transitions from admission through discharge ensuring continuity of care, alignment of services, and post hospital referrals to continuing care agencies. Also serves as a resource for nursing, physicians and ancillary departments on transitional and regulatory issues The Case Manager will experience working with culturally diverse patient populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. Will be responsible for assessment, service planning, resource acquisition, monitoring progress and initiating the responding to emerging client needs..
- Provides comprehensive and client centered service planning and coordination for a specified group of high-risk patients.
- Manages care of prioritized TCRHCC/SPHC outpatient/inpatient based upon consultation from providers within the TCRHCC/SPHC healthcare delivery system; provides a consistent and on-going consultation with service providers.
- Works collaboratively with providers and other disciplines to develop and maintain high risk patient database to ensure the continuity of care is established and maintained for the TCRHCC/SPHC outpatient/inpatient population.
- Works proactively and collaboratively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and Purchased Referred Care (PRC) at TCRHCC/SPHC.
- Facilitates communication and coordination between members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services (CMSA, 2010).
- Independently develops and maintains resource database to ensure timely and accurate information for patient referrals and minimize fragmentation in patient care services.
- Develops with the patient/family and multidisciplinary team (including service area and/or other non-TCRHCC/SPHC providers as appropriate) a care and service delivery plan based upon the needs identified and available provider and financial resources of the patient and provides consistent and on-going case consultation with all direct service providers.
- Provides service monitors and follow up to ensure continuity of care, and updates of the client service plan and provides follow up if needed. Striving to promote client self-advocacy and self-determination (CMSA, 2010).
- Prepares patient and family for termination (discharge) from case management when services are no longer required. Arranges for any ongoing support/direct care services that the patient will need post-discharge in coordination with discharge planners and other entities such as PHN, Community Health Representatives or Tribal Social Services. Will provide follow-up phone call for high risk patients.
- Develops reports, performance improvement projects, establishes policy and procedures and program objectives.
- Will provide Case Management coverage for the Adult Care Unit, Pediatric Unit, Intensive Care Unit, Obstetrics Unit, Emergency Room and Outpatient Departments.
- Will be familiar with Advance Directives and be a resource person for patients and families; facilitate informed choice, consent, and decision-making.
- Promote use of evidence-based care, as available, in conjunction with the MCG Care Guidelines.
- Pursue professional excellence and maintain competence in practice.
- Serves as the outpatient/inpatient coordinator, such as:
- The primary contact for outpatient/inpatient in obtaining beds for admissions both within and outside of TCRHCC/SPHC.
- Collaborates with provider and nursing personnel to ensure admissions are conducted seamlessly and without delay of patient care.
- Collaborates with provider, nursing personnel and patient benefits coordinators that all admission documentation is complete and all referrals for third party resources are complete prior to the departure of patients.
- Required to take call on scheduled weekends as deemed necessary.
- Responsible for electronic health records data entry pertinent to patient service role.
- Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.
- Performs Other Duties as Assigned.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Work frequently requires walking, reaching and sitting. Work also requires extensive periods of time maintaining balance and working at a personal computer. Work does occasionally require the ability to stand, drive, bend, climb, kneel, crouch, and twist. Must be able to lift, pushing and pull up to 10 lbs. frequently and up to 25 lbs. occasionally (i.e. medical charts); must be able to distinguish numbers, letters, and colors. The incumbent must have prolonged ability of far, near, color vision; depth perception; see fine details; hear normal speech; hearing overhead pages on a loudspeaker; and use a telephone. Must also have prolonged ability of hand manipulation to simple and firm grasping; fine manipulation and use of keyboards. Incumbent must be able to accept a flexible schedule to meet unit needs.
Contacts often require tact and sensitivity as those related to stressful situations such as death, dying and catastrophic illnesses. Must be able to prioritize, use good judgment, and coordinate a variety of issues while being frequently interrupted. Incumbent must have the prolonged ability to cope with high level of stress; make decisions under high pressure; manage altercations, anger, fear, hostility in others in a calm way; concentrate; handle high degree of flexibility; handle multiple priorities in stressful situation; work alone; demonstrate high degree of patience; adapt to shift work; and work in areas that are close and crowded.
Incumbent may be exposed occasionally to the following environments: Infectious disease, chemical agents, and loud noises.