The Case Manager:

• Coordinates and facilitates interdisciplinary provision of comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions.
• Fosters achievement of optimal health care outcomes within accepted standards of care.
• Serves as an expert resource to the healthcare team regarding the continuum of care, efficient use of resources, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements.
• Ensures a smooth transition of care between multiple health care environments with planned handoffs.
• Partners with patients and families in identifying health care issues and barriers to self-care in order to set priorities and engage in appropriate interventions.
• Demonstrates cultural agility and employs health literacy guidelines to provide education regarding self-management strategies.
• Utilizes rapid quality improvement cycles to continuously monitor, evaluate, measure, and report progress of interventions and outcomes.
• Paces the case to assure appropriate and fiscally sound care coordination across the continuum.

Facilitates daily multidisciplinary care coordination meetings to clarify patient plan of care.

Communicates with patients and their families concerning the progress of patient recovery goals and ongoing care needs.

Organizes and/or participates in patient care conferences.

Coordinates care and expected outcomes between patients/families and healthcare team including nurses, social workers, physicians, therapists, and community agencies and resources.

Develops and maintains a collaborative working relationship with all team members.

Follows evidence-based best practice.

Serves as the clinical resource manager for patients with complex care needs.

Provides consultations for patients who do not follow or have multiple variances from a pre-established clinical path.

Assesses patient care priorities with patient and staff as part of the health care team and participates in determining outcomes of interventions.

Collaborates with patient, family, and other health care professionals in the establishment of goals and implementation of patient plan of care.

Facilitates referrals, multidisciplinary review and planning for specific patients.

Maintains currency in case management practice and principles specific to venue.

Ensures transition plan reflects national guidelines and/or approved protocols/pathways.

Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.

Assists patient care team to identify and coordinate appropriate level of care across the health care continuum.

Focuses on promoting early intervention for complex patients and communicating a coordinated plan of care to prevent unnecessary complications and negative patient outcomes.

Communicates with UM RN(s) and with insurance and community case managers, when appropriate, to discuss benefits and obtain authorization for alternative level of care.

Assists health care team to incorporate the educational needs of patients and/or families concerning alterations in health and the disease process into the plan of care.

Assists with patient and family education as appropriate and necessary.

Collaborates with Legacy leadership to identify educational needs of staff.

Participates in and/or leads committees and task forces.

Participates in identifying needs and developing programs which facilitate attainment of organizational goals.

Represents applicable clinical areas in the review and development of hospital and overall system policies, procedures, protocols, guidelines, and standards.

Participates in Continuous Quality Improvement (CQI) activities.

Participates in data collection, analysis and reporting of defined indicators to facilitate comprehensive evaluation of program impact.

Collaborates with Legacy management team and staff in developing and utilizing quality indicators to monitor and evaluate care and outcomes.

Participates as an active member in department meetings and group problem-solving sessions.

Sponsors changes to improve department operations and supports others’ suggestions for change.

In setting professional goals, includes attainment of case management certification.

Education:

Academic degree in nursing (BSN or higher) preferred.

Experience:

This position requires extensive knowledge of disease management to include diagnostics, treatment and prognosis, community resources and healthcare reimbursement. Minimum 2 years clinical nursing experience required.  Relevant experience in one or more of the following healthcare areas preferred:
Coordination of community resources
Care management of diverse patient populations
Ambulatory Care
Knowledge of levels of care throughout the health care continuum to include; inpatient, emergency care, rehab, home health, hospice, long term acute care, SNF, ICF, ALF with an overall understanding of utilization management and resource management.
Working knowledge of Care Management models across the continuum.

Knowledge/Skills:

Knowledge of six core components of case management:

Psychosocial aspects

Healthcare reimbursement

Rehabilitation

Healthcare management and delivery

Principles of practice i.e.  CMS guidelines, Interqual criteria

Case Management concepts

Excellent organizational skills

Health literate oral and written communication skills for effective interaction with all members of the patient’s health care team

Knowledge of transitional planning to and from all venues

Ability to determine and access appropriate community resources

Ability to engage patient/family in discussion of health care goals and decisions with attention to cultural and health literacy implications

Ability to adhere to and implement regulations in an effective manner.  Must serve as a resource to all team members regarding regulatory issues.

Keyboard skills and ability to navigate electronic systems applicable to job functions.

LEGACY’S VALUES IN ACTION:
Follows guidelines set forth in Legacy’s Values in Action.

Equal Opportunity Employer/Vet/Disabled

Current applicable state RN licensure.  Case management certification preferred.  AHA BLS for Healthcare Providers required for all employees who perform this job in the state of Oregon.