Nurse Case Manager - Clinic

About This Role

This clinic-based role is a critical part of the patient's care team, focusing on evaluating patients and initiating telemedicine visits within the clinic setting. The Nurse Case Manager will provide quality healthcare while adhering to all applicable laws, regulations, and policies within their scope of practice, working with patients throughout the Hilton Head area.

Responsibilities

• Facilitate receiving all medical records from the patient's primary provider and specialists
• Review medical records
• Complete consents with patients
• Enroll patients in Care Management, if they meet eligibility criteria
• Initiate a Care Management Plan of Care, if the patient is eligible
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted
• Complete AWV's to be reviewed by the provider
• Complete cognitive impairment screenings
• Complete Social Determinants of Health (SDoH) assessments and/or screenings
• Complete ACP's to be reviewed with the patient by the provider
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient's quality of life
• Communicate and coordinate care
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments
• Provide post-discharge education
• Evaluate for adaptive equipment and DME
• Evaluate for safe environment
• Evaluation of acute condition(s) or follow-up from previous visit
• Appropriately and accurately document and log Care Management activities
• Work in conjunction with care team to keep the patients Care Management care plans up to date
• Coordinate with the patient's health care team, providers, physical and occupational therapists, home health or hospice representatives and other individuals in the patient's care plan
• Facilitate visits with appropriate provider or entity

Requirements

• Must be a licensed nurse; Registered Nurse preferred
• License must be in good standing with appropriate board/issuer
• A minimum of three (3) years clinical experience preferred
• Experience in community settings preferred
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers
• Strong written and verbal skills
• Basic computer knowledge
• Ability to manage and demonstrate effective leadership skills
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances