career center

Registered Nurse (RN) - Transitional Clinic Case Manager

PRN Day Shift

Bel Air, MD

1. Care coordination includes: screen and prioritize patient care needs; Assess physical/psychosocial needs and functional deficits of patients; Provide telephonic guidance; advice and support to patients; Set health improvement/health management goals for patients; Develop and maintain electronic care plan.
2. Communicates and collaborate regularly with the patient's clinical team, primary care provider, and community-providers (to include home health agencies, adult protective services, and patients' family as authorized by patient) on patient needs, concerns, treatment adherence and any changes to ensure seamless continuity of care.
3. Triage patient referrals and disseminate to the appropriate programs.
4. Triage patients in the clinic and telephonically to assess and identify acute or emergent problems, change in patient condition where intervention is needed, and questions related to patient's treatment plan.
5. Assist with conducting and coordinating plan of care between multi-disciplinary team within the department and our community partners.
6. Conducts patient's medication reviews, monitors, and evaluates patient biometrics data within the tele-monitoring portal, and contacts the patient and physician as needed.
7. Implements plan of care for the patient by performing evidence-based interventions and treatments specific to the diagnosis or problem of the patient: administers treatment such as, lab draws, start IVs, injections, nebulizer treatments, wound care as directed by provider, and monitors patients according to their needs and acuity level. Performs symptom-based standing orders and plan of care.
8. Educates patients about chronic diseases, medications/medication management and dietary needs to support the improvement of health conditions and lifestyle changes in an effort to reduce the need for medical intervention.
9. Accurately create a care plan based patients assessed chronic diseases, complex medical, and psychosocial needs.
10. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection
11. Participates in team-based care. Willingly accepts direction from providers and serves as a clinical resource to medical assistants and other practice team members. Communicates proactively.
12. Demonstrates professionalism; competence; and open communication style; high integrity; leads by example, high energy, creativity, diplomacy; and flexibility.
13. Participates in departmental initiatives and process improvement plans in an effort to maximize annual departmental goals.
14. Maintains professional development best practices and continuing education requirement for licensure. Staying up to date on population health guidelines and initiatives by participation in relevant educational programs and in-services.
15. Completes special projects and performs other duties as assigned.