Job Description

Schedule - Monday-Friday days

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview

The Medically Complex RN Case Manager serves the medically complex patient population at Children's Hospital & Medical Center and is a core team member to the continuity of patient care. The RN Case Manager acts in an expanded health care role to collaborate across the continuum with the CP care team, specialty care team, inpatient case management, social work, members of community health care teams, and patients/families to ensure the delivery of quality, cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans, including emergency plans, that are patient-centered, promoting quality and efficiency in the delivery of health care. Communicates effectively amongst diverse patient populations and providers. In partnership with the patient's medical health team, the RN Case Manager leads emergency care coordination within the team through process improvement, work flow redesign, providing assistance with training, and delegating to other members of the team.

Essential Functions

• Identifies targeted, high-risk populations within clinic site(s) per Provider referral/consults, risk stratification, registries, and/or patient lists.
• Assesses the health care (including emergency health care), educational, and psychosocial needs of the patient/family.
• Uses assessment tools such as assessments, screenings, functional assessments, and health risk assessments.
• Develops individualized patient/family education plans and emergency medical plans in collaboration with patient providers. Instructs and counsels patient/family regarding acute/chronic illnesses, use of emergency services, the use of prescribed treatments and medications, care coordination, and psychosocial needs.
• Provides patient self-management and emergency-management support with a focus on empowering the patient/family to build capacity for self-care and integrate health promotion into their lifestyle. Also empowers families to collaborate with local 9-1-1 systems and emergency departments, and in some circumstances initiating and coordinating contact through education events.
• Responsible for developing a comprehensive, individualized plan of care and emergency care plan, both with targeted interventions.
• Implements clinical interventions and protocols based on diagnosis, risk stratification and evidence-based clinical guidelines.
• Continually monitors patient/family response to plan of care and revises the care plan and emergency care plan as indicated.
• Collaborates with Providers, patients, families, and members of health care teams across a continuum of care settings and the community.
• Fosters a team approach and includes patient/family as active members of the team.
• Takes the lead in ensuring the continuity of care which extends beyond the clinic boundaries.
• Serves as liaison to acute care hospitals, specialists, post-acute care services and community agencies, including emergency medical services.
• Provides follow-up with patient/family when patient transitions from one setting to another.
• Completes timely post-hospital follow-up activities including medication reconciliation, Provider or Specialist follow-up appointments, review of discharge instructions, condition specific education, coordination of care, and assists in problem solving barriers.
• Maintains comprehensive medical record documentation on the appropriate information systems and databases using required documentation and billing guidelines.
• Utilize EHR activities to manage preventative care for patients.
• Assist in the development of adequate workflows to ensure patient care needs are met.
• Proactively reach out to patients most in need of care by utilizing EHR reporting tools.
• Facilitate the use of bulk ordering and communications with groups of patients.
• Manage the care of high risk patients using EHR patient outreach tools, which may include but not limited to: managing health maintenance, creating and tracking patient goals and completing appropriate patient assessments via telephone.
• Works with clinic and leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and the Patient Centered Medical Home delivery of care model.
• Participates in teaching/coaching clinic staff in the management of patient conditions. Assesses staff educational needs and develops educational programs. Promotes opportunities and activities.

Education Qualifications

• Bachelor's Degree from an accredited college or university in nursing Required

Experience Qualifications

• Minimum 4 years' nursing in pediatric setting Required

Skills and Abilities

• Demonstrated written and verbal communication skills. (High proficiency)
• Ability to apply the nursing process to patient care to achieve outcomes. (High proficiency)
• Current knowledge of the healthcare environment, including community resources. (Medium proficiency)
• Working knowledge of basic computer programs such as word, excel. (Medium proficiency)

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Required and
• BCLS - Basic Life Support through the American Heart Association Required and
• PALS - Pediatric Advanced Life Support within 180 Days Required and
• CPN - Certified Pediatric Nurse Preferred

Children’s is the very best for kids and the very best for your career! At Children’s, we put YOU first so together, we can improve the life of every child!