RN Case Manager (MAT)

The RN Case Manager (RNCM) is responsible for performing case management services for at-risk or high-risk patients at Mosaic Community Health. This at-risk or high-risk population may include patients with complex medical conditions, and/or socioeconomic and mental health co-morbidities.

Using the Nursing Process, assesses, plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. The RNCM will demonstrate and apply knowledge of the principles of comprehensive case management, patient-centered, culturally sensitive care coordination and management of complex patients.

RNCM’s may have a designated focus including Prenatal, Pediatrics, Adults, Transitional Care Management, Substance Use, or Street and mobile Medicine.

Responsibilities

• Patient Care and Care Management
• Manage a defined panel of high-risk patients with the goals of optimizing the patients’ health status and minimizing inpatient hospital and emergency department utilization.
• Collaborate with Quality, Value Improvement, and Population Health staff to identify high-risk patients.
• Implement evidence-based interventions and approved protocols for chronic conditions.
• Integrate evidence-based clinical guidelines, preventive guidelines, and approved protocols in the development of individualized, patient-centered care plans.
• Provide follow-up with patients/families regarding transitions of care, including medication reconciliation, timely follow-up appointments, patient education, and coordination of care.
• Organize and prioritize daily work by assessing new, current, and discharging patient needs in areas of responsibility. Complete documentation as required.
• Communicate and coordinate with internal and external care teams to ensure quality patient care is received and barriers to care and ongoing care plan are addressed.
• Assess health, educational, and psychosocial needs of the patient/family and develop, implement and evaluate care plans.
• Utilize behavioral strategies to provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Work closely with the patient’s primary care team to coordinate services and optimize patient care.
• Utilize available tools to facilitate close monitoring of high-risk patients and/or intervene early during acute exacerbations.