RN Case Manager - Madison Area

Job Description

Job Description

Job Title: Case Manager Registered Nurse (RN)

Department: Care Coordination
Location: Sequoia Integrative Medical Services
Reports To: Supervisor

Job Summary:

The Case Manager RN is responsible for providing comprehensive care coordination and case management services to patients across the continuum of care. This role involves patient assessment, care planning, resource management, interdisciplinary collaboration, patient advocacy, and follow-up to ensure quality care and positive health outcomes. The ideal candidate will have excellent communication skills, clinical expertise, and a commitment to patient-centered care.

Key Responsibilities: 1. Care Coordination:

• Assess patient needs through comprehensive evaluations, including medical history, psychosocial factors, and functional status.
• Develop personalized, interdisciplinary care plans in collaboration with patients, families, and healthcare teams.
• Arrange for necessary services, such as home health, rehabilitation, durable medical equipment, and community resources.
• Ensure seamless transitions between care settings, such as hospital discharge to home or rehabilitation.

2. Patient Advocacy and Support:

• Serve as an advocate for patients, addressing barriers to care such as financial concerns, lack of resources, or transportation issues.
• Provide crisis intervention and connect patients to mental health or social services when needed.

3. Monitoring and Follow-Up:

• Regularly monitor patient progress, adjusting care plans as necessary to align with changes in the patient's condition or goals.
• Conduct follow-up calls or visits post-discharge to ensure recovery and adherence to care plans.

4. Interdisciplinary Collaboration:

• Participate in interdisciplinary team meetings, providing insights into case management and addressing barriers to effective care.
• Coordinate with physicians, nurses, social workers, and therapists to align care plans and share critical updates.

5. Documentation and Compliance:

• Maintain accurate and thorough documentation of assessments, care plans, interventions, and outcomes in the Electronic Health Record (EHR).
• Ensure compliance with regulatory standards and organizational policies, including HIPAA and quality improvement initiatives.

6. Education and Resource Provision:

• Educate patients and families about treatment plans, medications, and available community resources.
• Provide disease-specific education and promote self-management strategies for chronic conditions.

7. Continuous Improvement:

• Use feedback and data to evaluate patient outcomes and improve case management processes.
• Participate in professional development activities to stay current with best practices in case management.

Qualifications: Education and Certification:

• Current Registered Nurse (RN) license in Wisconsin..
• BSN preferred. Case Management Certification is a plus.

Experience:

• Minimum of 1 year of nursing experience, with a focus on case management, care coordination, or discharge planning.
• Experience with EHR systems and care management software.
• Experience in chronic disease management or case management.
• Strong understanding of chronic conditions and treatment options.
• Excellent communication skills and ability to work collaboratively with patients and healthcare teams.

Skills and Competencies:

• Strong clinical assessment and problem-solving skills.
• Exceptional organizational and time management abilities.
• Proficiency in patient education and motivational interviewing techniques.
• Excellent interpersonal and communication skills for effective collaboration with patients, families, and healthcare teams.

Working Conditions:

• Remote and on location.  Locations vary but are local ALF, up to an hour drive in the Madison area, 25% of position is on site, 75% remote

Key Performance Metrics:

• Reduction in readmission rates and hospital stays.
• Improvement in patient satisfaction scores.
• Successful execution of care plans and positive health outcomes.