The RN Case Manager (CM) functions in a self-directed role w/ a high degree of autonomy in an expanded clinical role guiding approp use of resources for a variety of chronic conditions. RN Case Mgmt Services will have accountability for a designated population defined in conjunction w/ the clinicians in the medical home, & assists the organization in meeting regulatory service & care needs for these populations. The RN CM works collaboratively as a member of the health care team to deliver high quality health care to patients supporting KP's mission, vision & values. The RN CM provides a variety of nursing services both in person, by phone & via electronic media utilizing nursing process & leadership skills to address acute & chronic needs of Health Plan members & other patients of the KP Health Care Program. Works under the general direction of the designated supervisor & may function in multiple settings w/in the system, the community & home to provide support for a high risk population.
Essential Functions:
- Utilize reg'l population stratification info & processes to identify approp members for enrollment into case mgmt in collaboration w/ clinicians & health care team members of the medical home.
- Independently & proactively complete chart reviews, screening calls & full assessments related to the anticipated level of care & document findings using standardized approved documentation tools.
- Triage findings from member assessments, identifying needs & issues, engage patients to define a plan of care & approp level of self-mgmt & interventions.
- Determine Level of Care.
- Communicate findings & actions to involved care providers through succinct summaries that include findings, actions & further recommendations.
- W/ the member/family & approp KP staff & providers, develop & document a patient-centered care plan that addresses short term goals that are specific, attainable & measurable.
- Provide care coordination & mgmt services for members w/ identified needs: Creatively using available & approp resources, including KP staff & providers, to support the unique needs of each member.
- Facilitating access to internal & external services.
- Monitoring the effectiveness of the interventions.
- Reinforcing the treatment plan through life-style, diet & medication adherence including support for Chronic Condition therapies & Opiate Therapy Plan adherence.
- Advising & coaching patients & families.
- Succinctly document interventions in KP HealthConnect as needed by other providers to ensure coordination of care & services.
- Strengthen & improve Case Mgmt Services: Establish strong relationships w/ clinicians & other health care team members.
- Communicate data on population case managed, utilization & outcomes.
- Education of staff/clinicians.
- Development & distribution of education, tools & materials for member coordination.
- Contributing to ongoing process improvement including related procedures, policies, patient support & documentation tools.
- Act as a liaison between the Medical Home & Reg'l Case Mgmt.
- Assists w/ mgmt of diabetes patients on insulin & oral medications using protocol guidelines while achieving self mgmt goals.
- Provide patient education as needed over the phone.
- Ability to interpret data from diagnostic devices.
- Operate & instruct use of glucose monitors & approp diagnostic devices.
- Ability to identify & manage hypoglycemic events.
- Instruct in basic carbohydrate counting, diet modification & exercise plans.
Qualifications:
Basic Qualifications:
- Minimum six (6) years experience in acute care OR ambulatory care/clinic/extended setting within the last eight (8) years.
- Bachelor of Science in nursing or equivalent nursing experience (six (6) plus years), w/ the priority given to case management &/or care coordination.
- Graduate of Accredited School of Nursing.
- Current RN license in Oregon & Washington. Requires Oregon or Washington license at time of hire. Licenses in both states are required within six (6) months of hire.
- Nurse w/ current Oregon or Washington license in nursing.
- Current BLS w/ AED certification.
- Valid driver's license.
- Knowledge of case management principles.
- Demonstrates clinical nursing & leadership skills.
- Ability to work independently in an unstructured environment w/ minimal supervision.
- Able to type 20 words per minute.
- Demonstrates effective interpersonal, communication & problem-solving skills.
- Willingness to learn computerized information systems.
- Demonstrates ability to work within teams & within a dynamic work environment.
- Demonstrates customer-focused service skills.
- Knowledge of community resources for the care of the elderly, & patients w/ chronic conditions.
- Demonstrated ability to organize, coordinate, & manage care plans.
- Thorough knowledge of levels of care within outpatient, acute care, & extended care settings.
- Demonstrated ability to work as part of a multidisciplinary team.
- Effective written & verbal communication skills.
- Ability to present reports verbally in a public setting (public speaking).
- Demonstrated data entry skills & ability to use Microsoft Word software.
- Demonstrate & maintain knowledge of current diabetes practice.
- Ability to manage difficult patient populations w/ multiple co-morbidities.
- Identify risks & complications of diabetes.
- Thorough assessment skills (recognize barriers to care, able to assess current self management skills, able to identify knowledge gaps).
- Able to develop a plan of care for the patient.
- Appropriately apply protocols.
- Must be self motivated & able to work independently.
- Must be organized & able to effectively manage 40+ patients per 1.0 FTE.
- Understanding of the Endocrine system including DM pathophysiology & complications, including treatment of emergent situations.
- Knowledge of Type 1 & Type 2 diabetes, role/action of the various insulins/oral agents.
- Working knowledge of current diabetic tools being used by the diabetic population.
Preferred Qualifications:
- Minimum of two (2) years experience in case management, care coordination, or population care preferred.
- Previous experience w/ population care/case management, triage & advice preferred.
- Microsoft Word, Excel, & HC experience preferred.
- Quality management methodology & utilization management experience preferred.
- Previous experience w/ telephonic patient assessment skills, working from standardized policies & procedures preferred.
- 1000 hours in the past four (4) years in teaching diabetes self management skills preferred.
- Current or future bachelor's degree in nursing or related field preferred.
- Certified Diabetes Educator (CDE) preferred.
- CDE required within three (3) years of hire preferred.
- Certified Case Manager preferred.
Salary Range:
$33.10 - $47.60
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.