Outpatient Care Manager - Ambulatory Referral Coordination

EDUCATION & EXPERIENCE:

Minimum Qualifications:

• Bachelor’s degree in nursing or related field or equivalent AND
• Two years of case management experience or four years related experience.

Preferred Qualifications:

• Experience in oncology.

REQUIRED LICENSES, REGISTRATIONS, OR CERTIFICATIONS:

Required:

• Registered Nurse (RN).

Preferred:

• Certification in Case Management.

JOB SUMMARY:

To assess, counsel, educate and provide problem solving to assigned patient population. To provide timely and valid information to the interdisciplinary team, physicians and community partners related to the on-going and follow-up care of program specific chronic disease patients. Acts as an advocate for patients and coordinates and collaborates with the medical home to provide quality, cost-effective care and promote positive outcomes for all Integrated Care Team patients.

ESSENTIAL JOB FUNCTIONS:

• Screens and/or assesses patient and/or family to determine on-going care needs, identify barriers and solutions to self-management and health care access.
• Interacts with each patient at least monthly via telephone or in person contacts.
• Participates in activities that improve the quality and efficiency of patient care.
• Documents appropriately on all care management activities in the medical record and other departmental databases.
• Creates an individualized care plan that addresses the patient’s disease specific educational needs and works with the patient to set self-management goals.
• Coordinates patient care throughout enrollment in the program, ensuring that plans are communicated among the medical home practitioners, ancillaries and community partners caring for the patient.
• Enrolls patients in a timely manner based on department policy.
• Accountable for professional practice, including time management, clinical documentation, statistical and other record-keeping as needed. Reports as required to the appropriate Manager or designee.
• Facilitates productivity, team-building, and high team morale in the department.
• Attends educational seminars to keep abreast of current knowledge in the field of nursing, chronic disease and/or care management.
• Participates in the planning, development, implementation, and evaluation of special projects, programs, and research, as assigned.
• Participates in discharge planning as required.
• Attends staff meetings and participates in departmental problem-solving activities and performance improvement and quality assurance activities.
• Consistently communicates and displays oneself in a professional and courteous manner. Demonstrates productive problem-solving techniques and interpersonal relations.
• Practices and promotes the principles of patient confidentiality, including adhering to HIPAA guidelines on authorizations and documentation of disclosures of protected health information (PHI).
• Adheres