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RN Case Manager Outpatient
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Full-time
- 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 patient 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.
- 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.
- 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.
- Utilizes telephonic and face-to-face communication as appropriate to engage with and to meet needs of patients.
- A strong emphasis is placed 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.
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