Job Description

JOB SUMMARY:
The OP Care Management RN provides care management and population health services to patients. The primary target population served is the stratified risk patient or patients with high vulnerability at times of transition between care settings. OP Care Management RN will coordinate care around patient's chronic diseases, coordinate and facilitate medication management, and effectively manage care transitions across the continuum. OP Care Management RN will create a longitudinal, personalized care plan for each unique patient. Promoting effective partnerships between patients, families, nurses, physicians, and all other health care disciplines across the continuum. OP Care Management RN will use a data driven approach to manage patient populations to improve access to care and achieve optimal clinical outcomes.

EDUCATIONAL REQUIREMENTS
College Diploma in Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
Registered Professional Nurse (RN) License Illinois upon hire and Certified Case Manager within 2 years.

EXPERIENCE REQUIREMENTS
Three (3) year clinical nursing experience with Case Management experience preferred.

ADDITIONAL REQUIREMENTS

• Use of usual and customary equipment used to perform essential functions of the position.

SKILLS AND KNOWLEDGE
Possesses strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to patients with complex medical, emotional, and social needs. Effective behavioral and educational strategies, including but not limited to, motivational interviewing, teach-back method, and self-management support. Demonstrates high level of professionalism, leadership, communication, education, and collaboration.

ESSENTIAL FUNCTIONS:

• Communication and coordination between care settings across the healthcare continuum.
• Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships with patients, families and all other members of the care team.
• Provide education on medication adherence, follow up appointments, and other activities to maximize patient knowledge of self-care and reduce avoidable readmissions.
• Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
• Conduct holistic health care assessment including health risk assessment, patient preference and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity and social determinants of health.
• Ensure accurate documentation of clinical, financial, and other information using appropriate systems.
• Utilize data, dashboard, or other reporting mechanisms to support high reliability performance and outcome evaluation.
• Outpatient Care Management RN functions as an arm of the primary care provider to support any and all care coordination, chronic disease education for patients in collaboration with all cross-continuum care team members and support services.
• Documents within patient Electronic Medical Record (EMR) to support departmental specific workflows to ensure accuracy in care planning efforts.
• Effectively communicate with patients and all cross-continuum care team members in efforts to achieve optimal patient outcomes.

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