Case Management RN
The RN Case Manager will support the mission of the Ozarks Community Health Center. Our mission is to provide greater access to quality, compassionate, and professional healthcare through our comprehensive health system and community partnerships.
Strives to provide intensive care coordination and care management for patients, as well as address Social Determinants of Health for a medically complex population. Behaves in a manner consistent with the mission of OCHC and performs other duties as requested.
- 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.
Education & Training
- High School Diploma or equivalent with on the job training and demonstration of competency
- Must pass annual competencies
Licensure & Certifications
- RN or other professional license required
- BLS within 6 months of employment
- Health care experience preferred
- Health Home Coordinator
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This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.