RN Care Manager

Job Responsibilities

• Identifies high risk patients through provider/nurse referrals or chart review and maintains an up-to date panel of patients who do not fall into a case management program
• Develops a care plan with patient-centered goals and action plans for each patient
• Frequently communicates and coordinates with providers and other care team members about patient needs, goals, and action plans, including preventive and chronic care
• Manages panel enrollments and discharges as necessary
• Documents case management and care coordination notes within the EMR when patient contacts are made
• Tracks and updates patients’ required health assessments and screenings
• Manages patient assistance program
• Assists with referrals and prior authorizations as needed to ensure continuity of care
• Provides educational resources on medical diseases, treatment, and medications to patients and families
• Helps patients navigate the medical community including pharmacy and insurance
• Supports continuity of care by ensuring specialty providers’ records are obtained and scanned into the patient’s chart
• Reviews inpatient/ER discharge reports and makes contact with patients within 72 hours of discharge to review follow-up plan and reconcile medication list
• Works with Care Coordinator to obtain hospital/ER records from outside facilities
• Assists in care coordination by contacting medical providers and hospitals for admission, discharge, and referral information to share with providers
• Monitors Case Manager workload and assists in handling provider requests
• Assists rooming staff with on-the-floor nursing duties as necessary
• Provides crisis intervention as needed and appropriately documents hotline calls
• Actively participates in department and clinical team meetings and activities
• Participates in QI activities
• Other duties as assigned.