Type of Opportunity: Full Time
Work Schedule: Days
Responsible for case management of Home Healthcare patients. Ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state. Responsible for development, coordination and scheduling delivery of care through a multidisciplinary team to the patient in the home or community setting. The Case Manager assures completeness, timeliness and appropriateness of the patient care plan, its implementation and ongoing evaluation. Assures communication with the multidisciplinary team, support services and community resources to ensure that care goals are achieved in the most efficient and cost effective manner possible. Ensures that documentation is timely, accurate, complete and reimbursable. Is a patient advocate. Precepts newly hired nurses. .
PRN staff will not be responsible for managing a caseload; but all staff are required to manage the case load, follow up and communication for their daily assignments.
- Minimum one year acute care experience within the last 3 years required and hospice or home care experience preferred. Basic typing competency. Must have current drivers license as well as auto insurance.
- Associate Degree
- Registered Nurse-NM
Competencies and skills:
- SKILL-Ability to effectively interact with customers to understand their needs and explain data
- SKILL-Microsoft Office
Clinical Judgment and Action: Uses clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the patient care situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care. Critical Elements of Clinical Judgment and Action Performance Consistently uses the nursing process to structure and revise care Anticipates, recognizes, and responds to changes in condition Accurately communicates with healthcare team members to relay changes in patient status Consistently provides care based upon need and urgency Consistently applies patient safety principles Develops, plans, and evaluate patient short and long term care goals. Charts problems, plans and goals appropriately in NICP Consistently follows policies, procedures, standing order sets, care bundles, core measure practices Consistently follows red rules: Patient identification and hand-washing Seeks consultation if uncertain on how to respond to patient needs Adjusts care to establish and support care goals Integrates technology into daily care of patient by appropriate initiation of technology, maintenance, troubleshooting, and discontinuation *Consistently and accurately documents care per policies & standards
Patient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation. Critical Elements of Patient Advocacy Performance Maintains patient confidentiality/personal/medical information Identifies ethical and clinical issues Acts with integrated healthcare team using appropriate resources to resolve ethical/clinical issues Advocates for patient needs, values, and goals Compliance with JC Rights and responsibilities of the Individual elements
Clinical Inquiry: Uses high standards and evidence-based practices along with questioning, research and evaluation skills to provide informed and/or change practice Critical Elements of Clinical Inquiry Performance Supports process/quality improvement initiatives and incorporation into practice Follows and is informed on Department outcome measures Actively participates in changes in practice/roll outs *Seeks advice and consultation on care from colleagues and interdisciplinary team
Collaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomes Critical Elements of Collaboration Performance Provides and coordinates independent, interdependent, and dependent care interventions with interdisciplinary care team Selects appropriate Screenings from HED to facilitate interdisciplinary care when needed Appropriately delegates care, monitoring delegated team members care and responds as appropriate with the goal of optimizing care *Interactions with care team in respectful, professional manner
Facilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding. Critical Elements of Facilitation of Learning Performance Self: Completes all required learning modules, programs in specified time Self: Uses available resources within system to enhance own continuous learning Self: sets and achieves learning and performance goals yearly Self: Consults, teaches, supports continuous learning with colleagues Self: Actively seeks learning/mentorship Patient: Assess patient's learning style, readiness to learn, challenges to learning and adapts patient education to meet needs Patient: Incorporates patient in learning about diagnosis(es), care management, medications using appropriate verbal and written communication tools/resources
Response to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice. Critical Elements of Response to Diversity Performance Provides communication/ medical interpretation services for population served based upon language preference Consistently provides care to population served with appreciation to diversity elements as designated above Consistently communicates and documents patient diversity needs *Uses PHS established internal resources and vendors
System Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care. Critical Elements of Systems Thinking Performance Utilizes internal and PHS resources to provide evidence-based care including policy, protocols, procedures, approved specialty resources Incorporates all patient safety technology, tools, protocols, communications, and initiatives to optimize a safe patient environment Deploy in the clinical environment processes to enhance care efficiency, cost containment Plan, maneuver, and deliver services/technology that are available within the system to meet the care needs of the patient Negotiates within the system to achieve the care needs of the patient
- SKILL-Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff using strong dialogue and customer service competencies.
- SKILL-Written communication
Benefits are effective day-one (for .45 FTE and above) and include:
- Competitive salaries
- Full medical, dental and vision insurance
- Flexible spending accounts (FSAs)
- Free wellness programs
- Paid time off (PTO)
- Retirement plans, including matching employer contributions
- Continuing education and career development opportunities
- Life insurance and short/long term disability programs
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide health