Nurse Case Manager-Complex Care Management

Hawaii Island Community Health Center

Job Title: Nurse Case Manager-Complex Care Management

Department: Medical Services

Supervised By: Care Coordination Manager

POSITION FUNCTION SUMMARY:

Under the direction of the Care Coordination Manager the Nurse Case Manager will oversee enrollment and management of patients needing complex case management. The Nurse Case Manager is responsible to the HICHC clients for rendering a variety of skilled nursing care in assigned areas in terms of individualized client needs; according to dependent and independent nursing functions and conformance with recognized nursing techniques, procedures, and established standards based on the scope of nursing, under the direction/delegation of the Care Coordination Manager.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

This position may have various work assignments within HICHC. This description is intended to be generic in nature, and as such it does not detail all duties and responsibilities of the particular job assignment. Various duties, responsibilities and accountabilities may be assigned to an incumbent in this position depending on the specific job assignment, and may include but not be limited to the following:

POSITION SPECIFICATIONS:

Requirements of Position

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Complex Care Management:

• Assesses the physical, functional, social, psychological, environmental, and financial needs of patients.
• Identifies a cost-effective comprehensive care plan to meet the patient’s needs as well as the families’ service needs and implement the plan. Ensures that services are being delivered.
• Collaborates care with provider and integrates services with Behavioral Health specialists and other specialty services.
• Provides referrals to appropriate community resources; facilitates access and communication when multiple services are involved; monitors activities to ensure that services are being delivered and meet the needs of the client; coordinates services to avoid duplication. Works with HICHC referral specialist to provide appropriate services.
• Assesses the client’s formal and informal support systems.
• Maintains a case-management tracking system that focuses on high-risk populations.
• Acts as patient advocate; identifies and develops new community resources; assists with problem solving.
• Provides or assists in providing appropriate medical, nursing, or other health care in the home and/or clinic setting as needed.
• Maintains accurate patient records; maintains patient confidentiality.
• Provides and/or arranges for education in disease management; provides knowledge and tools so patients can manage their disease effectively including self-management goal counseling, assists in scheduling regular patient visits, and conducting periodic evaluations and knowledge updates.
• Helps maintain data and update flowsheets on specific disease management charts.
• Maintains records by observing and recording changes, progress, reactions, and treatments of assigned patients; suggests possible alterations and additions to the patient’s treatment plan.
• Educates patients by disseminating patient information and literature relating to health education programs including but not limited to family planning, pre-natal care, and health promotion/disease prevention for all age categories.
• Maintains compliance of clinic with state licensure by enforcing Quality Assurance protocols in the pharmacy, laboratory, medical supply, and nursing/patient care areas of HICHC for quality patient care.
• Maintains patient files by updating pertaining to medication refills, laboratory reports/results, patient medical visits, and other patient data/information required by the physician.
• Maintains and updates professional knowledge and skills and maintains clinical proficiency by attending continuing education or seminars related to job responsibilities, including Age Specific Training (care giving, treatment, and assessments specific to the age of populations served).

Education and Experience:

• State licensure as an LPN or RN required.
• One year of experience as a nurse required. Experience in a community health care setting preferred.
• BLS certification required.

Knowledge, Skills and Abilities:

• Advanced knowledge of clinical patient intake procedures, laboratory, and pharmacy protocols.
• Ability to use a computer to enter and retrieve patient data to complete a discharge plan. *make 2 separate bullets, and make more specific.
• Ability to work on multiple tasks within established deadlines.
• Ability to work independently under the general direction of a provider and follow instructions for work completion.
• Ability to take the initiative to resolve patient concerns and problems.
• Ability to work independently and autonomously in the absence of supervision.

Language Skills:

• Ability to read and interpret documents such as medical records, safety rules, operating and maintenance instructions, procedure manuals, accreditation standards and guidelines, etc.
• Ability to write at a moderate level of competence, including internal reports and memoranda.
• Ability to communicate with diverse groups of people to include staff and providers and patients.
• Ability to communicate effectively with patients and their families to make their visit a pleasant experience.
• Knowledge and sensitivity to the multicultural nature of the service area population. When doing so, such communication must be accurate and understandable by the recipient. If unable to do so, employee is required to secure the assistance of translation services with the appropriate language skill

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.