The Nurse Case Manager works in the Comprehensive CARE Center, a transitional clinic that works with patients recently discharged from the hospital. In collaboration with a multidisciplinary team, the nurse case manager is responsible for patients who are identified as high or potential high utilizers of the system to assess and assist in the coordination of patient's care across the continuum. Position functions as a clinician, case manager, and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization.

1. Assessment:
* Identify and assess high risk patients with chronic disease, complex medical, and psychosocial needs referred to the CARE Center
* Complete a thorough assessment with patient's history including medical, physical, social, emotional, psychological and financial needs that will assist the care team in developing a care plan
* Identifies barrier to health care, to include Social Determinant of Health (SDoH), and medical that focuses on the prevention of readmissions.
2. Care coordination:
* Provide telephonic guidance, advice and support to patients
* Accepts responsibility for patients Transition of Care to provide post-discharge follow-up to ensure medication reconciliation, follow-up appointments with PCP or specialist, and other special assistance as needed
* Communicate with multi-disciplinary team any pertinent findings causing a delay in care coordination to ensure safe and efficient services
3. Medication Reconciliation:
* Interview patient/family to identify home medications
* Assess patient/family knowledge of their medications
* Assess patient/family's ability to afford medications
* Review discharge medications
4. Implement 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.
5. Accurately create a care plan based patients assessed chronic diseases, complex medical, and psychosocial needs.
6. Educate patient on complex medical needs in multiple learning environments, including, but not limited to, (telephonic phone calls, virtual support group, CARE Center visits, remote patient monitoring, home visits).
7. Promote and provide patient self-management, educating patients on disease, medication, access to care, and community resources/referrals to improve clinical outcomes and increase self-efficiency.
8. Conduct individual and group education sessions to assist patient/family in social-emotional needs that are impacted by living with a chronic diagnosis.
9. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.
10. Communicate with patients' primary care team (physician, nurse practitioner, social worker, case manager, etc.) regarding changes in patient status and/or care plan.
11. Participate in team-based care. Willingly accept direction from providers and serve as a clinical resource to medical assistants and other practice team members. Communicate proactively.
12. Establish an effective and appropriate means of communicating and collaborating with providers, team members, payers and ancillary services to ensure safe and efficient services.
13. Participate in educational programs and in-services supporting quality improvement and clinical efficiency initiatives.
14. Assist with special projects and other duties as assigned.