Job Summary
Facilitates a lifelong, proactive partnership with patients to enhance and personalize management of health related needs. Assesses needs, plans, coordinates and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily access resources and adopt healthy lifestyles that will increase their ability to remain in the most appropriate care setting. Focuses on five primary areas: 1) population management, 2) patient self-management support, 3) transitions in care, 4) resource connection, and 5) appropriate resource utilization.

Essential Functions
Works collaboratively and maintains active communication with the multidisciplinary care team including providers, pharmacists, social workers, behavioral health specialists, and nurses to achieve timely, appropriate patient management. Utilizes RN process as a framework to focus the activities of the healthcare team on the achievement of optimal outcomes, resource utilization, clinical expertise, and improvement strategies. Interacts with patients, professionals, and the community to achieve continuity of care, coordination of services and to document plans of care across multiple care settings. Conducts or participates in comprehensive “all-system” needs assessment for identified patients; knowledgeable of appropriate care-related services to match identified needs (including community resources), disease management for health maintenance, and appropriate clinical goal expectations/outcomes for identified population. Develops and maintains accurate case records of each referred customer/patient. Documents fully and accurately; knowledgeable of and utilizes accurate computer databases and documentation systems. Maintains knowledge of various reimbursement criteria and documentation necessary for reimbursement; including Medicaid, Medicare, and Managed Care. Demonstrates leadership in the professional practice of nursing. Physical Requirements
Work requires walking, standing, lifting, reaching, bending and stooping. Must lift a minimum of 35 pounds shoulder high. Ability to travel/drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight and hearing, finger dexterity, critical thinking and ability to concentrate. Must be able to respond quickly to changes in assignments. Occasional intermittent noise and exposure to conditions such as dust, fumes, and chemicals.

Education, Experience and Certifications
BSN required; Masters preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works required. 2 years experience required in health care. Experience includes case management/discharge planning in one of the following settings: Acute care, Home care, LTC care, Physician Office or Managed Care company. Obtain and maintain professional certification in a relevant clinical specialty, per departmental policy. Obtain and maintain BLS certification. Clinical competence in disease management and case management principles. Must possess excellent interpersonal communication and negotiation skills, problem-solving skills, strong organizational and time management skills, and the ability to work independently and as a member of the care team. Requires demonstrated knowledge and proficiency in appropriate tools.