Key Essential Functions and Accountabilities of the Job
- Responsible for the active management of SEARHC patients.
- Collaborates with the medical provider and all interdisciplinary team members to establish individualized medical goals that maximize patient healthcare outcomes.
- Coordinates multi-disciplinary care conferences for high risk or complex patients who are referred into the case management process.
- Manages panel acute and chronic care needs as well as health maintenance by continuously reviewing EHR reminders and triggers and providing outreach and education to patients.
- Participates in case management reviews where all high need patients are reviewed with a multi-disciplinary team of providers.
- Works with multi-disciplinary team as an advocate for the patient/client family at the service delivery level fostering patient/family decision making independence self-care and growth and development.
- Uses problem-solving and anticipatory skills in meeting the needs of the patient and the provider. Patient needs should be addressed in a prompt efficient manner.
- Facilitates the coordination of patient referrals within SEARHC other outside facilities. Tracks the progress of referrals and outcomes of care providing periodic status report to providers on outstanding referrals. Serves as the primary link for other case managers and discharge coordinators in care coordination for the patients. Ensures referral records have been received and are available for providers review. Proactively identifies delays and obstacles to care and works to remedy individual cases and to improve the process.
- Performs staff nursing duties in the various nursing roles in the clinic. Duties include assessment documentation education and administering appropriate medications and/or therapies.
- Maintains annual competencies including safety and infection control requirements. Performs duties as assigned in a responsible respectful and caring manner to promote effective nursing staff relationships. Maintains a clean and safe working environment including adequate supplies and upkeep of unit and equipment reporting any defective or missing equipment and safety hazards. Adheres to infection control policy and procedures.
- Communications and Teamwork
- Works collaboratively by building bridges and creating rapport with team members within departments and across the organization.
- Participates in department and clinic team and improvement efforts.
- Active member of the clinical team and is a leader amongst the pod nursing staff and unit coordinators.
- Participates in continued development of the case management role in primary care.
- As an RN is responsible for participating in the triage role and responding to emergency situations.
- Performs other duties as assigned including special projects deemed necessary to provide comprehensive health services.
Key Essential Functions and Accountabilities of the Job Responsible for the active management of SEARHC patients. Collaborates with the medical provider and all interdisciplinary team members to establish individualized medical goals that maximize patient healthcare outcomes. Coordinates multi-disc...
Key Essential Functions and Accountabilities of the Job
- Responsible for the active management of SEARHC patients.
- Collaborates with the medical provider and all interdisciplinary team members to establish individualized medical goals that maximize patient healthcare outcomes.
- Coordinates multi-disciplinary care conferences for high risk or complex patients who are referred into the case management process.
- Manages panel acute and chronic care needs as well as health maintenance by continuously reviewing EHR reminders and triggers and providing outreach and education to patients.
- Participates in case management reviews where all high need patients are reviewed with a multi-disciplinary team of providers.
- Works with multi-disciplinary team as an advocate for the patient/client family at the service delivery level fostering patient/family decision making independence self-care and growth and development.
- Uses problem-solving and anticipatory skills in meeting the needs of the patient and the provider. Patient needs should be addressed in a prompt efficient manner.
- Facilitates the coordination of patient referrals within SEARHC other outside facilities. Tracks the progress of referrals and outcomes of care providing periodic status report to providers on outstanding referrals. Serves as the primary link for other case managers and discharge coordinators in care coordination for the patients. Ensures referral records have been received and are available for providers review. Proactively identifies delays and obstacles to care and works to remedy individual cases and to improve the process.
- Performs staff nursing duties in the various nursing roles in the clinic. Duties include assessment documentation education and administering appropriate medications and/or therapies.
- Maintains annual competencies including safety and infection control requirements. Performs duties as assigned in a responsible respectful and caring manner to promote effective nursing staff relationships. Maintains a clean and safe working environment including adequate supplies and upkeep of unit and equipment reporting any defective or missing equipment and safety hazards. Adheres to infection control policy and procedures.
- Communications and Teamwork
- Works collaboratively by building bridges and creating rapport with team members within departments and across the organization.
- Participates in department and clinic team and improvement efforts.
- Active member of the clinical team and is a leader amongst the pod nursing staff and unit coordinators.
- Participates in continued development of the case management role in primary care.
- As an RN is responsible for participating in the triage role and responding to emergency situations.
- Performs other duties as assigned including special projects deemed necessary to provide comprehensive health services.
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