Description

The RN Case Manager (RNCM) is responsible for performing case management services for at-risk or high-risk patients at Mosaic Community Health. This at-risk or high-risk population may include patients with complex medical conditions, and/or socioeconomic and mental health co-morbidities.

Using the Nursing Process, assesses, plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. The RNCM will demonstrate and apply knowledge of the principles of comprehensive case management, patient-centered, culturally sensitive care coordination and management of complex patients.

RNCM’s may have a designated focus including Prenatal, Pediatrics, Transitional Care Management, and patients with multiple chronic conditions.

Patient Care and Care Management

• Manage a defined panel of high-risk patients with the goals of optimizing the patients’ health status and minimizing inpatient hospital and emergency department utilization.

• Collaborate with Quality, Value Improvement, and Population Health staff to identify high-risk patients.

• Implement evidence-based interventions and approved protocols for chronic conditions.

• Integrate evidence-based clinical guidelines, preventive guidelines, and approved protocols in the development of individualized, patient-centered care plans.

• Provide follow-up with patients/families regarding transitions of care, including medication reconciliation, timely follow-up appointments, patient education, and coordination of care.

• Organize and prioritize daily work by assessing new, current, and discharging patient needs in areas of responsibility. Complete documentation as required.

• Communicate and coordinate with internal and external care teams to ensure quality patient care is received and barriers to care and ongoing care plan are addressed.

• Assess health, educational, and psychosocial needs of the patient/family and develop, implement and evaluate care plans.

• Utilize behavioral strategies to provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.

• Work closely with the patient’s primary care team to coordinate services and optimize patient care.

• Utilize available tools to facilitate close monitoring of high-risk patients and/or intervene early during acute exacerbations.

• Resolve patient issues/concerns and/or route to appropriate staff. Consult with providers as needed

• Document all interactions in the EHR in a timely, thorough, and accurate manner.

• Educate patients and families about available Mosaic and community

• Deliver patient care within HRSA services scope and approved locations, encompassing patient homes, community-based sites, and providing home-based care when necessary and in adherence to defined services and safety protocols. Local travel required.

Skills & Knowledge

• Required: Superior nursing process skills. Critical thinking and problem-solving skills. Excellent written, verbal, telephone and interpersonal communication skills. Understanding of patient and family-centered care concepts. Strong organizational skills. Familiarity/experience with patient interaction on the telephone. Basic typing and computer skills and comfort with Microsoft Windows operating system.

• Preferred: EHR experience - EPIC experience a plus. Fluency in Spanish preferred. Involvement with quality improvement processes. Clinical system design and development. Motivational Interviewing experience. Knowledge of health insurance plans, standard office policies and procedures as well as regulatory requirements including CLIA and OSHA standards.

Who We Are

Mosaic Community Health prides itself on being an innovative health system that pioneers unique and creative ways to provide and improve patient access to health care. Since our founding in 2002 we have proudly served insured and uninsured patients regardless of age, ethnicity, or income.

We focus on a holistic approach to patient care by incorporating behavioral health, pharmacy, and nutrition support to serve patients in the most meaningful way. At Mosaic Community Health, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team based environment.

Mosaic Community Health offers more than just a job, it is a lifestyle. A lifestyle of serving others. A lifestyle of being an integral part of your community. A lifestyle that offers work/life balance. A lifestyle of enjoying the outdoors! Central Oregon offers over 300 days of sunshine a year, so enjoy a PTO day on the mountain, biking/hiking trails, or the river! A lifestyle that improves lives, including yours.

Qualifications

Education

Preferred

• Bachelors or better in Nursing

Licenses & Certifications

Required

• CPR

• Driver's License

• Registered Nurse

Experience

Required

• 2 years: Minimum two years of nursing clinical experience in acute or ambulatory care. Experience in nursing care of medically complex patients and/or case management in an ambulatory care setting preferred.