Description

*EDUCATION & EXPERIENCE:*
*Minimum Qualifications:*
* Bachelor's degree in nursing or related field or equivalent AND
* Two years of case management experience or four years related experience.
*Preferred Qualifications:*
* Experience in oncology.
*REQUIRED LICENSES, REGISTRATIONS, OR CERTIFICATIONS:*
*Required:*
* Registered Nurse (RN).
*Preferred:*
* Certification in Case Management.
*JOB SUMMARY:*
To assess, counsel, educate and provide problem solving to assigned patient population. To provide timely and valid information to the interdisciplinary team, physicians and community partners related to the on-going and follow-up care of program specific chronic disease patients. Acts as an advocate for patients and coordinates and collaborates with the medical home to provide quality, cost-effective care and promote positive outcomes for all Integrated Care Team patients.
*ESSENTIAL JOB FUNCTIONS:*
* Screens and/or assesses patient and/or family to determine on-going care needs, identify barriers and solutions to self-management and health care access.
* Interacts with each patient at least monthly via telephone or in person contacts.
* Participates in activities that improve the quality and efficiency of patient care.
* Documents appropriately on all care management activities in the medical record and other departmental databases.
* Creates an individualized care plan that addresses the patient's disease specific educational needs and works with the patient to set self-management goals.
* Coordinates patient care throughout enrollment in the program, ensuring that plans are communicated among the medical home practitioners, ancillaries and community partners caring for the patient.
* Enrolls patients in a timely manner based on department policy.
* Accountable for professional practice, including time management, clinical documentation, statistical and other record-keeping as needed. Reports as required to the appropriate Manager or designee.
* Facilitates productivity, team-building, and high team morale in the department.
* Attends educational seminars to keep abreast of current knowledge in the field of nursing, chronic disease and/or care management.
* Participates in the planning, development, implementation, and evaluation of special projects, programs, and research, as assigned.
* Participates in discharge planning as required.
* Attends staff meetings and participates in departmental problem-solving activities and performance improvement and quality assurance activities.
* Consistently communicates and displays oneself in a professional and courteous manner. Demonstrates productive problem-solving techniques and interpersonal relations.
* Practices and promotes the principles of patient confidentiality, including adhering to HIPAA guidelines on authorizations and documentation of disclosures of protected health information (PHI).
* Adheres to internal controls and reporting structure.
*Marginal or Periodic Functions:*
* Performs related duties as required.
*WORKING ENVIRONMENT/EQUIPMENT:*
Hospital, ambulatory care or community environment. Conditions such as noise, odors, cramped workspace and/or fumes could sometimes cause discomfort. Moderate physical effort may be required such as walking, standing and lifting materials, equipment and/or objects. May be exposed to occupational hazards such as communicable diseases, and disoriented or combative patients and/or family members. Some local travel required.
*SALARY RANGE:*
Actual salary commensurate with experience.
*WORK SCHEDULE:*
On-site, Access Services, Monday through Friday, 8 am to 5 pm.
*Equal Employment Opportunity*
UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.