Title:RN Case Manager Reports to:Director of Managed Care FLSA Status:Exempt Personnel Supervised:None

POSITION SUMMARY: The RN Case Manager will have direct and indirect patient care responsibilities. This position will work in collaboration with the managed care team, clinical care team, including pharmacy to ensure optimal outcomes for patients health. The primary responsibility of this position is to deliver safe, high quality, and efficient primary care to a patient population diverse in age, health status, and socioeconomic level with focus on adult primary care. Secondary responsibilities include but are not limited to providing direct nursing care to patients by providing patient education, phone triage, and appointment scheduling. Works with healthcare staff to obtain appropriate clinical documentation for review of medical necessity by payors. As a Case Manager (RN), you will work with referral sources from the healthcare community to plan and direct services to meet the needs of individuals while assessing medical necessity in accordance with Medicaid and Medicare guidelines. This position requires strong leadership and communication skills, and an excellent knowledge base of family medicine primary care nursing.

MINIMAL QUALIFICATIONS:

• Education: Graduate of an accredited School of Nursing
• Experience: Registered Nurse, Preferably one year of case management
• License: Florida unrestricted license
• BLS certification
• Computer literacy

KNOWLEDGE AND SKILLS:

1. Knowledge of current professional nursing theory, practice, and techniques
2. Knowledge of current nursing practices in an outpatient primary care setting
3. Knowledge of assessment of patient needs and services
4. Knowledge of current professional nursing and pharmaceutical products, Universal Precautions, and emergency situations
5. Knowledge of basic pathophysiology of diseases commonly managed in Family Medicine
6. Knowledge of the application of nursing techniques (example: Triage, blood pressure monitoring, glucose monitoring, etc.)
7. Knowledge of patient teaching and education (example: self-blood pressure monitoring, nutrition instruction, diabetes self-care instruction)
8. Knowledge of general patient care and treatment procedures, equipment, rules, regulations, and ethics
9. Knowledge of Utilization Review Accreditation Commission (URAC) Policies and Procedures
10. Knowledge of processing and obtaining prior authorizations
11. Knowledge of making observations of general physical condition and needs of patients and when to confer with a physician about the emotional or physical condition of a patient
12. Knowledge of the principles of aseptic and sterile techniques and infection control techniques
13. Knowledge of the techniques of administration of common medications, including immunizations, inoculations, and allergy injections using sterile technique, and knowledge of the side effects of these medications
14. Knowledge of state and federal drug control laws, rules, and regulations
15. Knowledge of emergency techniques and procedures
16. Knowledge of common medical supplies and equipment
17. Excellent interpersonal, communication and leadership skills
18. Ability to demonstrate priority-setting and ability to work in a complex environment
19. Ability to function with a high degree of independence and collaboration with other health care providers
20. Commitment to service, quality, and departmental core values

RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:

1. Be familiar with CFHCs program philosophies, goals and objectives. Be cognizant of and comply with all CFHCs policies and procedures, as well as state and federal regulations.
2. Be competent in performing the duties of a nurse.
3. Understand the requirements of CFHCs Exposure Control Plan. Personally, utilize universal precautions when practicing in a clinical setting.
4. Participate in staff outreach and off-site health care programs as requested by the DMC, ACMO, CMO, or CEO. Represent CFHC in the community.
5. Report as needed to DMC and any pertinent information or situations that impact on patient care or CFHC liability.
6. Attend and participate in mandatory CFHC meetings (Center Specific meetings, Corporate meetings, and other meetings as designated by the DMC, DOP, CMO, or CEO).
7. Demonstrate ability to work cooperatively with other members of the clinical team. Be supportive of coworkers.
8. Maintain a neat and professional appearance at all times.
9. Carry out any other activities deemed appropriate by the DMC, CMO, or CEO.

Primary Dutiesinclude, but are not limited to, the following:

1. Assess, identify problems, plan goals, monitor and evaluate patient plans, and develop strategies that meet the patients immediate and long-term goals.
2. Work closely with PCP to manage patient care items which could include; medication refills per protocol, lab triage, document management, management of durable medical equipment (i.e. Glucometer, test strips, lancets), prior authorizations of needed medications or other services.
3. Use patient data to track and schedule follow up appointments.
4. Provide proactive utilization management for patients with high risk needs.
5. Assist patients in obtaining appropriate medications and medical supplies and equipment, including coordination of pharmaceutical patient assistance programs.
6. Participate in quality improvement, quality assurance and innovation activities to ensure optimal level of care delivery.
7. This position will ensure all HEDIS measures have been met for those assigned patients and all care gaps have been identified.
8. Assist in the coordination of warm hand-offs or transfer of trust between care team, pharmacy or other support services during the office visit.
9. Carry out other duties as assigned by the DMC.