Description

JOB SUMMARY: The RN Case Manager is responsible for screening and assessment; problem identification; care planning; implementation and coordination of care; monitoring the care process; and reassessment of status/plans, directed toward the improvement of Franklin Primary Health Center’s patient health status.

DUTIES AND RESPONSIBILITIES:

1. Participate in assessment and planning (immediate, near-term and long term) for the care needs of patients referred for case management. These care needs will extend across the continuum of care from the acute hospital admission to maximum recovery or death.

2. Coordinate services for individuals who have diverse, relatively long term, and complex treatment requirements due to a catastrophic illness or injury, such as:

• End stage complex chronic disease such as congestive heart failure, diabetes with multiple organ system complications, end- stage renal disease requiring dialysis or widespread malignancy treated with chemotherapy and/or radiation therapy

• Severe trauma or burn injuries

• Recent major surgery with complications

• Individuals who have frequent emergency department or urgent care visits

• Elderly patients who live alone and require multiple medications

3. Facilitate and coordinate care plans with physicians, hospital or facility staff, and family to develop an acceptable plan for necessary post-acute care.

4. Provide benefits appropriately (neither less nor more than in the patient’s Health Plan contract) and seek community resources available and helpful to the patient such as ‘Meals on Wheels’.

5. Provide current status reports, verbally and in writing, to other providers – particularly the primary physician.

6. Initiate, promote and integrate the case management program as a functional extension of overall medical care and other services available throughout the community.

7. Provides psychosocial assessment and individual care plan development for each patient at initial clinic appointment (FPHC Case Manager Form). Assessment and care plan will be updated at least annually or when there are significant changes in patient's psychosocial status.

8. Advises all patients that the specialty program will be notified of inactive participants and all patients will be removed from active status if clinic appointments are not kept for a six-month period of time.

9. Provides documentation in FPHC chart of all:

a. Face to face patient contacts

b. Telephone contacts (patient and collateral)

c. Community referrals

1. Food stamps

2. Transportation

3. Housing

4. Counseling

5. Employment

d. Financial assistance referrals

1. Medicaid (all patients)

2. Federal/State Drug Reimbursement Programs (all eligible patients)

3. Drug company’s reimbursement programs (all eligible patients)

4. Medicare (all eligible patients)

10. The Case Manager will personally assist in the completion of Medicaid, Medicare, and state drug reimbursement and drug company’s applications. Copies of all applications for financial assistance/reimbursement will be placed in patient's chart.

11. All case management documentation will be in black or blue ink with entries dated and signed. Signatures will immediately follow documentation with "Case Manager" designation.

12. Provides assistance in securing community funding for physician ordered medications and/or diagnostic tests not covered under clinic protocols. Physicians will complete referral form and submit to the Case Manger who will document disposition

13. Conducts and document three separate attempts to contact patient to re-schedule after each missed appointment. Attempts may be by telephone, letter, or home visit. A minimum of two methods may be utilized.

14. Documents and track all financial assistance and reimbursement referrals activities. Tracking will be done routinely and disposition documented.

15. Provides monthly list of new patient referred for financial assistance/reimbursement and monthly status reports of patients previously referred until disposition.

16. Provides the following monthly reports to Program Coordinator/Director, Social Services Director and Medical Director:

a. All face to face and collateral contracts with clinic patients.

b. Patients who have missed clinic appointment and results of tracking activities.

c. Patients who have not been seen in the clinic in six months.

d. All active clinic patients

e. All active clinic patients who have expired during the month.

Qualifications

EDUCATION AND EXPERIENCE:BSN or Associate Degree in Nursing, graduate from an accredited school of nursing with three years’ work experience. Case management experience preferred. Must have a valid Alabama Driver's License.

KNOWLEDGE, SKILLS AND ABILIIES: Knowledge of case management practices and services to give and evaluate patient care. Knowledge of organizational policies, regulations and procedures to administer psycho-social assessment and care plan for patient care is required. Skills in establishing and maintaining effective working relationships with patients, medical staff, and the public are required. Skills are required in preparing and maintaining records, writing reports, and responding to correspondence. Abilities to maintain quality control standards. Abilities to interpret, adapt and apply guidelines and procedures. Must possess the ability to communicate clearly and maintain confidentiality.