Job Information
Arnot Health Office Patient Case Manager - Population Health in Elmira, New York
Job Description
MAIN FUNCTION:
Responsible for managing and coordinating the patient’s care among the other office patient-centered care team members, community agencies, and other facilities to promote continuity of care, improve patient compliance, and improve overall patient health, utilizing evidence-based methodologies. Provides nursing services, as needed, to facilitate effective patient care in practice. This position reports to Outpatient Services Director of Nursing and Clinical Services.
DUTIES AND RESPONSIBILITIES:
- *CASE MANAGEMENT:
a. Ensures adequate and appropriate follow-up regarding medical concerns, referrals and diagnostic testing by conferring with patients via various modes of communication (i.e: telephonically, electronically and/or in person).
b. Serves as patient’s liaison to office practice, soliciting phone calls from patients regarding all aspects of care, but particularly as it relates to follow-up testing, referrals, or development of new problems or questions.
c. Actively participates in and supports patient care with emphasis on patient compliance, monitors providers’ plan of care to assess progress and completion of all items, explains any changes in plan of care including prescriptions, diagnostic testing, referrals and/or procedures, allays fears and elicits cooperation and patient compliance.
d. Monitors patient gaps in care reports regularly; completes patient outreach (telephonic or electronic) to ensure appropriate care and compliance.
e. Works closely with patient’s primary nurse and other members of the office patient-centered care team to coordinate patient’s care.
- *NURSING PROCESS:
a. Assesses and cares for patients under the direction of Provider. Supervises care of licensed practical nurses and medical assistants in the office setting.
b. Provides patient assessment in an ongoing and efficient manner focusing on the whole patient, including physical, cognitive and behavioral needs
c. Determines patient’s care history, including test results, hospitalizations, ED care, urgent care, community care, referral to consultants, etc.
d. Provides age appropriate care to patients.
e. Triages patients to gather medical concern or prescription concern information for provider.
f. Informs provider with any changes in plan of care.
g. Implements an established plan of care in a knowledgeable, skillful and consistent manner.
h. Carries out physician pre-approved standing orders to provide efficient and effective care.
- *PATIENT EDUCATION:
a. Demonstrates awareness, sensitivity and knowledge of patient/family learning needs and implements appropriate measures to meet their needs, rights, and safety.
b. Utilizes educational information with explanation/directions, focusing on self-management, self-efficacy and beneficial behavior changes.
c. Provides comprehensive education to patients on new procedures, medications, etc. and documents.
d. Provides education on population management, with referrals to adjunctive community services and disease management programs, as per provider order.
- *DOCUMENTATION/OFFICE PROCEDURE:
a. Documents accurate, concise information in the patient’s EMR in a timely manner.
b. Documents all interactions with patients, consultants, community agencies, or other facilities in order to facilitate the coordination and management of patient’s care.
c. Documents all orders carried out under provider or provider-approved standing orders.
i. Vital signs
ii. Problem list
iii. Allergy list
iv. Medication list / medication reconciliation, Prescription refills (either electronically or paper)
v. Fall assessment / pain assessment / learning evaluation / functional limitation
vi. Communicable Disease history
vii. Other modules: PMH/FMH, Tobacco/Alcohol/Supplements, substance abuse, mental health history as well as test results, hospitalizations, ED care, urgent care, community care, and referrals to consultants since the last office visit.
- CARE TEAM PARTICIPATION:
a. *Participates in processes that promote a functional care team, including periodic team meetings and electronic messaging.
b. Participates in the practice’s performance evaluation and quality assurance activities.
c. *Assists other members of the patient-centered care team to carry out their duties, practicing within the limits of his/her scope of practice (Registered Nurse).
- EDUCATION:
a. *Participates in the annual mandatory education as required by position.
b. *Completes Merit Fair, including a module on population health, in which patients’ needs are proactively addressed to optimize the overall health of the population.
c. *Performs effective patient communication, particularly with vulnerable populations, eg. Patient coaching and motivational interviewing.
d. Has knowledge of Aseptic Technique.
e. *Attends mandatory in-services, including AIDET (acknowledge, introduce, duration, explain, thank you), which fosters effective communication with patients.
f. Independently participates in continuing education courses to meet own professional growth.
g. Maintains a record of all educational activity.
- ADDITIONAL OFFICE RESPONSIBILITIES:
a. *Schedules follow-up visits, consultations, referred testing and surgeries as per provider orders.
b. *Obtains pre-authorizations in a timely manner for medical testing, medications, etc.
c. Isresponsible for coding/billing preparation for billing department, medical necessity and insurance referrals.
d. Processes and directs laboratory specimens in an appropriate and timely manner, submitting necessary billing information to the laboratory.
e. Assists with clerical duties such as chart preparation, filing, and floor stock inventory/ordering in the office when required.
f. Keeps rooms stocked with appropriate medical supplies and instruments, maintaining current expiration dates and removes excess, unused supplies.
- *SAFETY:
Demonstrates and functions with awareness of safety issues as identified by the institution towards patients, co-workers and self.
- *EMERGENCY SITUATIONS:
Performs efficiently and appropriately in emergency situations.
a. Is aware of location of Emergency Box in their office setting.
b. Is current in CPR certification.
c. Maintains and documentsdaily seal integrity of office Emergency Box and performs monthly AED battery check.
- *PROFESSION:
Maintains professional conduct and appearance.
a. Is courteous and respectful to patients/families and co-workers.
b. Is aware of dress code and dresses accordingly.
- *LEGAL ISSUES:
Demonstrates awareness of basic legal issues in all aspects of patient care, office functions and strives to minimize risks.
- OUT-PATIENT OFFICE TESTING/PROCEDURES:
Is competent to perform/assist provider with patient diagnostic testing, procedures, such as EKG, spirometry, sterile procedures, etc., if required in the office setting.
- MEDICATION COMPETENCY:
Demonstrates competency in medication administration with provider order for oral, IM, SQ meds as well as nebulizer treatments.
a. Follows policy and procedure regarding medication administration.
b. Performs immunizations according to the providers instructions andaccurately documents information in the patients EMR.
c. Is responsible for maintaining clean, orderly drug sample cabinets and adheres to Outpatient Services policy for sample meds.
- FAMILY PRACTICE OFFICE ONLY:
Nurse is familiar with:
a. State mandated ( NY, Pa )VFC programs/age requirements/documentation.
b. Vaccine Refrigerator Setup.
c. Monthly care of vaccine storage units and required documentation. Maintains current Outpatient Services/VFC required temperature/problem log.
- *INFECTION CONTROL:
Performs all aspects of universal precautions when in patient care and maintains current Infection ontrol Certification as required by New York State (not a requirement for nurses practicing in Pennsylvania).
- *PATIENT-CENTEREDNESS:
Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with the Medical Center.
- OTHER:
It is understood that this job description lists typical duties for the classification and is not considered inclusive of all duties, which may be assigned.
EDUCATION:
Graduate of an approved RN program with current New York State or Pennsylvania licensure.
EXPERIENCE:
Previous nursing experience in a medical office setting preferred. Excellent communication and writing ability.
CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:
Basic Life Support (BLS) required within 30 days of hire date. Advance Cardiac Life Support (ACLS) required in critical care units.
PHYSICAL DEMANDS:
Employee required to be on his/her feet much of the time, some lifting, reaching and stooping involved.
EXPOSURE CATEGORY:
Category I. Tasks that involve exposure to blood and body fluids/tissue.
**A.D.A. Essential Functions
Requirements