Population Health RN Inpatient Case Manager

At NorthBay Health The Population Health RN Inpatient Case Manager (PHRNICM) is responsible for providing complex case management (CCM) to diverse groups of high-risk capitated populations. Complex case management is defined as the coordination of care and services for members who need help navigating the healthcare system to facilitate the appropriate delivery of the right care and services at the right place and time. These services are provided utilizing available resources across a continuum of care and in collaboration with members, caregivers, medical home providers, and ancillary health care providers. NBH utilizes a Population Health approach to identify diverse groups and to enhance member engagement and coordinate care delivery across populations to improve clinical outcomes. In addition to continuum of care responsibilities this position will assist within the inpatient case management department as needed.

At NorthBay Health, our vision is to be the trusted healthcare partner of choice for the communities we serve. We are dedicated to improving the well-being of our community by providing accessible, high-quality care to all who need it. Every member of our team plays a vital role in delivering compassionate and effective healthcare solutions. We invite you to join us in our mission to ensure that every patient and family member feels valued, respected, and cared for throughout their healthcare journey.

JOB SUMMARY

Under direction of the Manager, Utilization Management the Population Health RN Case Manager (PHRNCM) is responsible for providing complex case management (CCM) to diverse groups of high-risk capitated populations. Complex case management is defined as the coordination of care and services for members who need help navigating the healthcare system to facilitate the appropriate delivery of the right care and services at the right place and time. These services are provided utilizing available resources across a continuum of care and in collaboration with members, caregivers, medical home providers, and ancillary health care providers. NBH utilizes a Population Health approach to identify diverse groups and to enhance member engagement and coordinate care delivery across populations to improve clinical outcomes

PRIMARY JOB DUTIES

1. Identify patients who are considered high risk for medical care resource utilization by reviewing information from referrals placed in the electronic health record (EHR). Referrals may also come through ED, Pharmacy, Hospital, and other departmental or systems reporting.
2. Conducts assessments to identify the member’s needs and develops a specific care plan to address objectives, barriers, and goals identified during the assessment.
3. Comprehensively identify strengths and opportunities for patients, including physical, behavioral and social support system capacities and degree of engagement with providers.
4. Follow-up with patients and providers on identified health care needs and identify possible resources to address those concerns and/or work with care management team to address concerns in a multi-disciplinary method.
5. Facilitate and manage referrals from referral specialist, providers, and other care management staff to ensure that identified red flags and healthcare needs of patients are addressed.
6. Provide individual consults to patients on health education issues. Develop the health awareness of individuals, as well as groups and organizations, empowering them to make better health choices.
7. Provide specialized oversight, implementation of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures.
8. Identifies “at risk” individuals and applies clinical based guidelines for development of a comprehensive plan of care. Obtains and evaluates relevant information (medical, psychosocial, financial) utilizing interviewing skills.  Advocates for patients and their families throughout their episode of care. Maintains availability to patients/families as a resource to facilitate communication among providers and to monitor services rendered. When appropriate, meets directly with the patients and their families based on identified needs. Collaborates with patient, family, physicians and the interdisciplinary team to develop individualized comprehensive plans of care and to identify needed changes to the plan throughout care continuum.  Remains involved until the patient achieves the planned level of functional health or closure criteria are met.
9. As appropriate, coordinates/meets directly with the patient/family and the interdisciplinary team based on identified needs.  Provides patient/family or significant other with information about appropriate providers.
10. Involve the patient and their support systems (i.e. caregiver, family, etc.) in t