RN/Case Manager

Essential Duties

RN Case Management:

Plan, teach, supervise and counsel patients regarding physical care measures to promote improvement/recover, symptom/complication management, expected disease progression, social/emotional care and community resources.

1. Act as a comprehensive care coordinator for patients by assessing the patients' needs accordingly and facilitate communication amongst other clinicians providing care.
2. Perform comprehensive assessments of physical, emotional, psychosocial, and environmental needs of the patient including outcome and assessment information.
3. Identify significant clinical findings, make conclusions and intervene appropriately.
4. Demonstrate the knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status.
5. Interpret the appropriate information needed to identify each patient's requirements relative to his or her age-specific needs.
6. Provide the care needed as described in the Agency's Policies and Procedures.
7. Develop and implement a realistic individualized Plan of Care (Physician's Plan of Care, Home Health Aid Plan of Care) for each patient, evaluate and revise this plan as necessary.
8. Compare assessment data to baseline assessment to monitor patient's progress. Recognize alterations in function, including life-threatening situations. Intervene and document appropriately.
9. Participate in development of patient goals and discharge plans as well as make revisions to these based on the changes in patient status.
10. Initiate patient education based on identified learning needs of the patient and / or those providing care. Document appropriately.
11. Prioritize nursing visits based on the patient's health status and anticipated needs.
12. Demonstrate the skill and judgment necessary to implement physician orders, nursing procedures and nursing interventions.
13. Assume on-call responsibilities as per on-call needs.
14. Implement physicians orders accurately and promptly, using nursing judgment.

Referrals:

1. Contact other medical facilities to obtain patient appointments as directed by Providers:
   1. Referrals to Wishard, Methodist, Riley, other specialists (radiology, ultrasound, MRI, CT, Mammograms or other diagnostic tests).
   2. Provide external facility with required referral documentation.
2. Ensure patients are eligible for Shalom Advantage, Little Red Door, BCCP or other special assistance programs.
3. Notify patient of appointments made for tests or appointment specialist.
4. Match test results with patient chart for Provider review:
   1. Retrieve and print results from appropriate hospital information system, if possible.
   2. Receive results via fax or U.S. Postal Service.
   3. Pull patient chart and attach results for Provider review.
5. Ensure Front Desk Associates have adequate supply of BCCP packages. Obtain additional packages as needed.
6. Use of eClinical Works referral process, including P2P and Patient Portal.
7. IHIE Quality Health First Program
   1. Run monthly Patient Attribution Reports for each Shalom Provider.
   2. Run monthly Patient Alerts and Reminder Reports for each Shalom Provider.
   3. Submit the requested data to IHIE via online site.
8. Oversee the Reach Out and Read Program:
   1. Place order for books.
   2. Keep reading room organized.
   3. Keep providers updated regarding availability of books for children.

Education & Qualification Requirements:

• Graduate of an accredited School of Nursing, College or University, holding at least one of the following combinations of education & experience:

1. Baccalaureate Degree in Nursing (BSN) and 1 year experience in home health care hospital or outpatient setting providing case management services; OR
2. Associate's Degree or Diploma in Nursing plus 3 years' experience in home health care, hospital or outpatient setting providing case management services.

• BLS trained with current certification.
• Bilingual – English/Spanish a plus.
• Computer literate (MS Word, e-Clinical Works, etc.).
• Excellent interpersonal skills.
• Excellent verbal and written communication skills.

Certifications/Licensures:

• Current CPR certification
• Current and valid RN license in Indiana.

Knowledge, Skill, Ability and Work Difficulty:

• Able to provide health care in a sensitive, nonjudgmental manner to persons of all economic levels and cultural backgrounds.
• Medical office practices, procedures and equipment.
• Correct English/Spanish usage, spelling and grammar.
• Assists with recognizing the needs and concerns of people within their cultural framework.
• Examines and verifies financial documents and reports.
• Ability to work independently from general instructions.
• Communicates clearly and concisely both orally and in writing.
• Recognizes and maintains confidentiality of work materials.
• Interprets Shalom's services and policies to patients and families.
• Works independently in the absence of supervision.
• Self-motivated and flexible to daily patient schedule and/or clinic needs.
• Deals with public and staff, both in person and over the telephone, in tactful and professional manner.
• Understands Shalom's relationship with the community and maintains positive image and relationships.
• Ability to travel day-to-day within assigned geographic areas.

Physical Demands and Work Environment:

• Pass a physical examination after being offered employment and a health assessment annually, thereafter.
• Clear annual TB, influenza, and other communicable disease testing.
• Perform under pressure of patients and clinic staff needing assistance to meet deadlines.
• Reposition a bedbound patient alone, as needed.
• Exposure to indoor office florescent lights.
• Exposure to computer monitor.
• May be required to stand or sit for prolonged time period.
• May be required to bend stoop, kneel, pull, climb, reach, lift, and perform repetitive movements of the upper extremities.
• Requires normal hand-eye coordination and dexterity.
• Requires normal vision capability.
• Distinguish letter, numbers or symbols.
• Requires lifting up to 20 pounds frequently and 50 pounds infrequently.
• Able to perform one person transfer under routine and emergency situations, as needed.
• May be exposed to small amounts of hazardous materials.
• May be exposed to unsanitary conditions in some home settings.
• May be exposed to high crime areas within the service area community.
• Exposure to weather and temperature extremes.