The primary function of the RN Case Manager is to work as part of the patient care team in providing high quality, efficient, and service-oriented patient care while demonstrating Aviva Health’s core values. The RN Case Manager will work alongside physicians, advanced practitioners, clinic nurses and medical assistants to provide care coordination, medical and disease education to patients, and serves as a liaison between the patient and provider to resolve care concerns as they arise and carries out tasks as directed by medical providers. The RN Case Manager will participate in Quality Improvement, COVID-19 Case Management, Triage Services, Annual Wellness Visits, Chronic Care Management, Transition of Care, and Complex Case Management Model of Care programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Reviews patient history, medication list, diagnostics, and outside records to implement an appropriate plan of care for the patient as defined by the provider.
• Familiarity with the complex needs of a population with multiple medical, social, and psychosocial obstacles in achieving and maintaining wellness and stability
• Explains procedures and treatments to patients and provides patient education on various health-related topics
• Develops and implements patient care plans for high-risk patients by reviewing patient history, medication list, diagnostics, and outside medical records from other facilities.
• Communicates with providers, patients and family members regarding care plans, goals and expected outcomes.
• Communicate care plans with hospitals, skilled nursing facilities, home health agencies, pharmacies, and vendors, including scheduling and participating in case conferences.
• Ensures effective documentation in the EMR of activity such as test results, medication management, and adherence to follow-up appointments.
• Responds to patient telephone calls as needed.
• Coordinates transitions in care for patients (post-hospital discharges).
• Provides chronic care management based on standard nurse practices.
• Provides nursing assessment for patients with complex medical needs.
• Provides preventative health assessments in the form of annual wellness visits, medication review, nurse visits, etc.
• Completes point of care testing per nurse standing orders and communicates results with providers.
• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
• Develop systems to prevent errors (e.g., effective medication reconciliation).
• Triage of phone calls and walk-in patients for acuteness of need and/or priority of intervention and document assessment information of all activities.
• Participate in chart review/nurse peer review.
• Clinical nursing functions that may include, but are not limited to, blood draws, IV insertion and IV fluid/medication administration per provider order, suture/staple removal, foley catheter insertion/removal/management, wound care, coumadin management, staff training, vaccinations, perform nurse visits (scheduled and walk-ins).
• Participates in QA/QI activities.
• Coordinates and delivers patient education related to disease process and medications to individuals and group of patients.
• Other duties as assigned.

QUALIFICATIONS:

• Possession of current Oregon RN license in good standing.
• Possession of current CPR certification.
• Previous experience in Case Management required.
• Minimum of 1-3 years of clinical experience in a Clinical or Hospital setting.
• Disease Management in a clinical setting.
• Proficient computer skills including MS Word, Excel, PowerPoint, and Outlook.
• Previous experience with electronic medical records highly preferred.
• Able to multitask and work independently.
• Strong organizational and interpersonal skills.
• Excellent verbal and written communication skills.
  

  PHYSICAL REQUIREMENTS:

• Standing 20% of the time; walking 30% of the time; sitting 45% of the time; lifting and carrying 5% of the time; and able to carry up to 25 pounds. Pushing/pulling, bending, stooping, twisting, reaching and handling, climbing stairs (Elevator available).
• Hearing: within normal limits with or without use of corrective hearing devices.
• Vision: adequate to read 12-point type with or without use of corrective lenses.
• Must be able to verbally interact with staff, clients and public.
• Manual dexterity of hands/fingers for writing, computer input.
  

  WORKING CONDITIONS:

• Work indoors in heat-controlled environment 95% of the time.
• OSHA Exposure Category
  • OSHA Exposure Category – Category#1: Possible job-related exposure to blood and/or body fluids. Requires the appropriate use of person protective equipment PPE).