Nurse Case Manager

Job description

Job Summary:
The Nurse Case Manager provides comprehensive case management, Chronic Care Management (CCM), and Remote Patient Monitoring (RPM) services to support patients in achieving their health goals and effectively managing chronic conditions. This position provides patient assessment, education, ongoing monitoring, care coordination, and follow-up while serving as a key liaison between the patient, primary care provider, and community resources. The RN Case Manager promotes patient engagement, identifies barriers to care, and connects patients with appropriate medical, behavioral, social and community-based services.
Supervisory Responsibilities:
None.
Duties/Responsibilities:
• Provides active case management services to an assigned caseload, assessing patient needs, developing individualized care plans, coordinating services, and monitoring progress toward established health goals.
• Provides Chronic Care Management (CCM) services for eligible patients, including ongoing assessment, education, care coordination, follow-up, and documentation in accordance with program requirements.
• Provides Remote Patient Monitoring (RPM) services for eligible patients, including patient enrollment, education, monitoring of submitted data, follow-up, identification of concerning trends, and communication of significant finding to the appropriate provider.
• Conducts home visits to observe the patient’s home environment, assess safety and functional needs, and identify factors within the home that may affect health, treatment adherence, or the ability to manage chronic conditions. Recommends appropriate interventions and communicates relevant findings to the care team.
• Educates and empowers patients and caregivers regarding chronic conditions, medications, self-management strategies, treatment plans, healthy behaviors, and available resources.
• Maintains ongoing communication with patients through meaningful conversations, outreach, and follow-up to assess progress, address concerns, reinforce goals, and support engagement in their care.
• Serves as a liaison between patients and providers, communicating patient concerns, preferences, progress, and changes in condition to the appropriate members of the care team and carrying out provider-directed care activities.
• Identifies barriers, risks, and unmet needs that may affect a patient’s ability to achieve health goals, including access to care, transportation, financial concerns, social needs, health literacy, and other social determinants of health.
• Coordinates referrals and community resources by connecting patients with appropriate medical, behavioral health, social, public health, and other community-based services and following up to promote successful linkage.
• Completes patient assessments and screenings to identify healthcare needs, eligibility for case management services, and opportunities for care coordination or additional support.
• Documents patient assessments, care plans, interventions, communications, RPM/CCM activities, and follow-up accurately and timely in the EHR and other required systems, in accordance with applicable standards and program requirements.
• Collaborates with internal and external care partners to promote continuity of care, support transitions between healthcare settings, and facilitate communication among patients, providers, hospitals, health departments, and other community resources.
• Maintains professional knowledge and competency related to chronic disease management, care coordination, RPM, CCM, patient education, and evidence-based nursing practice.
• Performs other duties as assigned.

Duties 1 through 13 are designated as ADA Essential Functions and must be performed in this job. All other job duties are secondary functions.
Knowledge, Skills, and Abilities:
• Ability to efficiently carry out Midtown Health’s Center mission statement and comply with its policies and procedures.
• Ability to establish and maintain effective working relationships with patients, co-workers, and the public and to be able to demonstrate cultural awareness and sensitivity.
• Must be able to maintain strict confidentiality of sensitive information in accordance to HIPAA regulations.
• Ability to comply with all occupational safety and health standards and all rules, regulations, and orders issued under the Occupational Safety and Health Act (OSHA).
• Ability to utilize critical thinking and problem-solving skills to address clinic’s needs.
• Ability to interpret oral and written instructions and do appropriate follow-up.
• Ability to work independently and as a team member.
• Must have exceptional time management and organizational skills.
• Ability to constructively participate in quality improvement efforts.
• Ability to actively participate in marketing and outreach activities when requested and emergency response events when required.
• Bilingual (English/Spanish) verbal and written skills highly desired.
• Must have knowledge and ability to practice in accordance with the State of Nebraska's Nurse Practice Act.
• Must consistently exercise discretion and judgment to analyze, interpret, make deductions and then decide what actions are necessary based on the varying facts and circumstances of each individual case.
• Must have excellent interpersonal and communication skills in one-on-one and group situating and using the telephone.
• Must have knowledge of community resources and have the ability to assess need for referral.

Education and Experience, Licensure and Certification:
• Nursing degree from an accredited college/university required.
• Two years of nursing experience in a clinical setting or case management preferred.
• Must have a current unrestricted license as a Nurse (RN, LPN, BSN) in the State of Nebraska.
• Current certificate in Basic Life Support (BLS) required.
• Must successfully complete Clinical Health Coach-v-Fusion training within first year of employment.
• Must have a valid driver’s license and the ability to utilize own transportation for work purposes.

Physical Requirements:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Maintain physical condition appropriate to the performance of assigned duties and responsibilities which may include sitting or standing for extended periods of time.
• Must have the ability to exert up to 20 pounds of force occasionally and/or a negligible amount of force constantly to move objects.
• Requires frequent bending, stooping, or stretching.
• Ability to reach by extending hand(s) and arm(s) in any direction.
• Finger dexterity required to manipulate objects with fingers rather than with whole hand(s) or arm(s), for example, using a keyboard.
• Vision and hearing within normal parameters to perform job requirements.

Working Conditions/Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Ability to work varied and extended hour scheduling as requested including early mornings, evenings, and occasional weekends.
• Ability to work in a smoke-free and drug-free work environment.
• This position works with mentally ill individuals where a high degree of stress is possible.

Other Duties:
This job description is not designed to cover or contain a comprehensive listing of duties or responsibilities that are required of the employee for this job. Duties and responsibilities may change at any time with or without notice.
EEO Statement:
Midtown Health Center is an equal opportunity employee and will consider all qualified candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or because he or she is a protected veteran.