High Risk Nurse Case Manager (Healthcare)
A registered nurse who is part of the primary care practice team and is responsible for organizing, coordinating, and providing care coordination and care management services to patients within the practice.
The High Risk Nurse Case Manager acts as an integral part of the primary care team and is responsible for ensuring that the primary care physician (PCP) and practice team maintains a central role in coordinating and managing the care of these vulnerable patients.
The High Risk Nurse Case Manager is responsible for a panel of 60-75 complex patients. S/he will work with a team including behavioral health, case management, and primary care to establish goals and a plan of care for each complex patient. The RN CM is the point person for complex patients, making sure that services are coordinated and communicated between all team members and the patient's primary care provider (PCP).
The highest risk patients are:
1) Transitioning to or from home and community-based health care facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services, or other community-based services;
2) Being seen in the office with co-morbidities, unmanaged disease severity, poor self-care, polypharmacy, and high utilization rates.
GENERAL DUTIES & RESPONSIBILITIES:
Primary objectives of the position: