Location: Grand Island
About Heartland Health Center:
Heartland Health Center provides comprehensive medical, dental, and behavioral health care services to Grand Island and surrounding communities. As an integrated care clinic, our providers work collaboratively to serve all aspects of patients' health care needs. Heartland believes that that exceptional, compassionate care should be accessible and affordable for all.
Position Summary:
Heartland Health Center (HHC) is a Federally Qualified Health Center (FQHC) dedicated to providing affordable and comprehensive primary healthcare and dental services to uninsured, under-insured, and low-income individuals and families in Grand Island and the surrounding communities.
We are seeking a Registered Nurse (RN) Case Manager to enhance the health, wellbeing, and satisfaction of patients with chronic and complex diseases. This role involves monitoring patient compliance with disease-specific clinical guidelines, educating patients and their families about their conditions, and conducting ongoing assessments of health-related needs.
The RN Case Manager will assist with medication refills, perform phone triage to address patient concerns, and review incoming provider documentation to ensure accuracy and compliance. Additionally, will collect patient data to monitor health status and proactively manage patients' conditions, focusing on lifestyle changes related to chronic illnesses.
Essential Functions:
- Collaborates, advocates, and confers with multidisciplinary teams to develop and implement individualized care plans based on PCP, referral, and discharge information.
- Analyze referral documents and ER/discharge summary reports to evaluate patient conditions and follow-up recommendations, facilitating smooth transitions of care.
- Track patient outcomes and follow-up on referrals to ensure compliance and address any barriers to care.
- Assess new patients
- Update and revise patient health care plans as needed
- Educate patients and families about health care plans and options
- Make clinical decisions for routine patient care
- Accurately document and submit medical records
- Demonstrate knowledge in medical care; such as diagnostic procedures, medication, symptoms, and other treatment-related therapies
- Works to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance case management and patient Centered Medical Home delivery of care model.
- Provide emotional support to patients and families
- Evaluate and determine needs of patients
- Review results from medical tests, referral and hospital documents, and laboratory testing
- Implement physician orders and other nursing procedures
- Integrates skills and knowledge of pathophysiology, epidemiology, clinical management, cardiometabolic conditions, and self-management of chronic illnesses into clinical practice.
- Advocates for and communicates about improved quality of care and outcomes for those living with, at risk for, and affected by chronic health conditions.
- Actively participates in the quality improvement (QI) process and adapts practice/process based on QI findings.
- Partners with individuals to deliver care and education conducive to behavior change and improved quality of life for self-management of chronic health conditions across the lifespan.
- Completes comprehensive assessments for each patient including emotional and behavioral health, interprets personal health data, develops an individualized care plan based on the patient’ assessed needs and goals and promotes successful self-management.
- Documents all individual contacts/visits in the Electronic Health Record in a timely manner.
- Advocates for and supports technology-enabled education and care.
- Collaborates with community partners to establish and maintain on-going support options.
- Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
- Participates in meetings, serves on committees, and represents the department and hospital/facility in community outreach efforts as appropriate.
Education and Experience
- Current State of Nebraska license as a Registered Nurse. BSN is preferred.
- Experience in the development, planning, and evaluation of patient educational programs.
- Minimum of three (3) years of previous nursing experience preferred.
- Knowledge of physical assessment, pathophysiology, pharmacology, and management of acute and chronic diseases.
- Excellent needs assessment, care planning and implementation skills.
- Experience with EMR (Electronic Medical Records).
- Must possess an awareness of and sensitivity to cultural diversity and the various socioeconomic levels of our patients, families, and staff members.
- Computer skills desired include: Word, Outlook, and Excel
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, sit; use hands and fingers to handle or feel objects; reach with hands and arms; and talk or hear at normal ranges within the setting. The employee occasionally is required to bend, stoop, kneel, crouch and/or crawl. The employee is occasionally required to climb or balance. The employee must occasionally lift, carry, and/or move more than 25 pounds. Rapid mobility may also be required on occasions. Specific vision abilities required by this job include close vision, peripheral vision, depth perception, and the ability to adjust focus. Stress level may be high due to frequently dealing with physicians, family members, and other healthcare providers.
Job Type: Full-time
Benefits:
401(k)
401(k) matching
Dental insurance
Employee assistance program
Flexible spending account
Health insurance
Health savings account
Life insurance
Loan repayment program
Paid time off
Professional development assistance
Vision insurance
Schedule:
Experience:
License/Certification:
Ability to Relocate:
Work Location: In person