Case Manager Outpatient - RN

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Day (United States of America)

As a member of the Population Health Management (PHM) Team, the Outpatient Case Manager works with members, providers and caregivers to provide intensive, comprehensive case management and increase efficient utilization of services for patients with complex needs; identifies chronic, complex and or catastrophic cases through the case management process and or referrals and initiates intensive case management according to program guidelines.

This role will utilize multiple disciplines as CM to focus on various different patient populations. The goal of the PHM OP Case Manager is to effectively manage patients on an outpatient basis and during episodes of acute hospitalizations (in conjunction with their inpatient counterparts) to assure the appropriate level‑of‑care is provided, optimize safe transition to home or the next level of care, prevent inpatient re‑admissions and ensure that the patients' medical, environmental and psychosocial needs are met over the continuum of care.

The Case Manager acts as an advocate for members and their families linking them to other appropriate disciplines on the care team to facilitate patient/family education for better self‑management, navigation of the health care system, and to identify community resources as necessary.

• Matches the patient/family needs to available and appropriate resources to carry out the plan of care. Utilizes telephonic and face‑to‑face communication as appropriate to engage with and to meet needs of patients.
• Prioritizes and collaborates with patients/families/healthcare providers regularly to optimize patient engagement and clinical outcomes in the most efficient manner.
• Coordinates patient care services necessary to meet patient needs. Makes appropriate referral to other team members to assist with resource needs.
• Strong emphasis on Wellness, Disease Management and patient education to ensure compliance with the plan of care and prevention of complications with various ailments and chronic conditions.
• Identifies care gaps and works with the team to close the gaps.
• Coordinates member visits with primary care providers and specialists as needed.
• Reviews all patient referrals to determine criteria met for case management.
• Performs comprehensive assessment to identify patient/family needs.
• Identifies all high‑risk areas, including medical, environmental and psychosocial areas.
• Reviews all options/resources available to meet client/family needs and to promote optimum health and the most cost‑effective manner.
• Collaborates with the patient/family, physician and multidisciplinary team in the formation and modification of a comprehensive and individualized plan of care which addresses the needs and goals of identified high‑risk patients with complex chronic conditions.
• Integrates evidence‑based clinical guidelines, preventive health guidelines, protocols, and other identified risk information in the development of plans of care that are patient‑centric, promoting quality and efficiency in the delivery of healthcare for high‑risk population.
• Develops and/or utilizes processes that monitor patients across the health continuum with a focus on effective and safe transitions from hospital to home, nursing home or rehab facility with goal of optimizing resources and reduction of avoidable acute care readmissions.
• Monitors care through data collection and analysis.
• Evaluates processes utilizing a systematic approach to determine the effectiveness of the case management plan in terms of reaching desired outcomes and goals to improve the quality, access and cost of care.
• Manages performance…