Job Summary

The Population Health RN Case Manager works collaboratively with physicians, interdisciplinary teams, patients, and families to promote positive patient outcomes. Performs a care continuum process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to support the individual's health needs, utilizing skilled communication, education, and resources to promote quality and cost-effective outcomes. Provides focused support to various areas such as utilization management, value-based performance team, emergency department, acute, ambulatory, and specialty care teams.

Duties include assessment to identify member needs and development of a specific care management plan to address past, present, and ongoing care needs. In conjunction with the Physician, implements care/treatment plan by coordinating access to health services across multiple providers/ disciplines, monitors care, makes determination to arrange transportation and transfer patient if indicated, identifies cost-effective measures, makes recommendations for alternative levels of care and utilization of resources, promotes medication management, telehealth/remote care options, self-care management, and ensures paperwork is completed. Is an indirect caregiver.

Key Responsibilities

• Interfaces with Primary Care Physicians, Specialists, and various disciplines on the development of case management plans/programs.
• Monitors and evaluates the effectiveness of the case management plans and modifies as necessary.
• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, value-based care, and transfer coordination, discharge planning, and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families.
• Acts as a clinical liaison, per their specialty, with outside agencies and facilities, outside providers, employers, and/or workers' compensation carriers and third-party administrators.
• Acts as a patient advocate and educator to ensure that the patient has the knowledge to care for his/her condition and is educated and empowered to be responsible for participating in the plan of care.
• Prepares reports, communicates program changes to appropriate staff, and develops protocols in accordance with state regulations.
• Develops and updates training and educational materials and presents to appropriate staff, patients, and families.