RN Case Manager High Risk- OB Part time 20 hours week in Lynn, Massachusetts at Lynn Community Health Center

RN Case Manager High Risk - OB - Part Time, 20 hours

Summary:

The RN Case Manager will work with providers and team nurses to assure that the patients referred for Nursing Case management receive patient assessment, care planning, education, follow up and support in developing and achieving their health related self management goals; and best health outcomes. The RNCM collects, maintains, reports and follows up on related medical data. She/he assists in the development of day-to-day management and long term planning for the patient’s care. The RNCM collaborates with health center providers and multidisciplinary professionals in providing for physical, psychological and/or social support for assigned patients and families. She/he identifies and establishes relationships with community resources which can contribute to the network of care for patients. The RNCM meets the requirements of the designated funding source in achieving required program goals.

The RNCM may participate in community outreach efforts as appropriate and as assigned. This may include serving as a health consultant for the Lynn Public Schools, local day care centers, after school program, day camps or other community related organizations; providing such services as programmatic consultation, preparation/review of health related policies and documentation or participating in health screenings, health education programs or counseling at health fairs and other similar community events.

Qualifications:

• Graduate of an accredited nursing program.
• RN with current Mass. Licensure
• Previous experience in Community Health or Nurse Case Management preferred
• Bilingual in Spanish/Khmer/Russian beneficial
• History of good attendance and positive work attitude

Specific Duties and Responsibilities:

• Establish contact with patients appropriate for RN Case Management due to diagnosis, treatment regime, risk status, compliance, recent ER usage or Grant specified target group criteria.
• In collaboration with the PCP, Team RNs, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self Management goals. This plan may include medication management, diet counseling, exercise, referral for specialty care, education for proper use of medical equipment or supplies, update of immunizations, group or individual education and support.
• Coordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.)
• Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities. Provide for follow up of no shows.
• Consistently use the learning assessment, appropriate teaching guidelines, plan of care, EHR/EPM to review and document patient interventions.
• Develop and utilize patient case registry and data collection programs to track, record and summarize patient information for funding sources