RN Case Manager - Care Ally

Department: VBC Operations

Location: Eddy Street Campus – 211 N. Eddy Street, South Bend, IN 46617
Hours: 40 Hours Weekly | Monday-Friday

At The South Bend Clinic, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do.

With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits:

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

Responsibilities:

Patient Care / Patient Education

• Assumes an active role in the planning and implementing educational needs of assigned patients, with direct care team and need consultants:  Diabetic Educator, pharmacy, dietary, wound care, etc.
• Coordinates assigned patients' clinical care plan in conjunction with the Primary Care Provider and with appropriate team members and communicates the plan to patient/family in a timely manner. 
• Review services with interested patients and assist in enrolling them in the CCM program
• Provide all services necessary in order to execute an electronic care plan
• Determine an individual’s health and educational needs as a result of inbound and outbound phone calls, and review of medical records with patients
• Maintain communication with patients to measure no less than 20 minutes per month
• Collaborate with the patient's provider to facilitate appropriate physical, behavioral and social services
• Review care plans and make changes as necessary
• Provide patients with information regarding medical questions/concerns
• Examples of CM activities may include educating newly diagnosed patients about the disease and treatments; managing therapies; and drug administration and side effects 

Care Facilitation

• Develops, manages, and drives clinical plan of care with physician and multi-disciplinary care team.
• Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure timely patient management and facilitation of services.
• Coordinates patient care across the care continuum to reduce fragmentation of care and addresses/ resolve system issues that may be impeding progress and quality of care for patients.
• Focuses on management of the complex patient with the goal of patient self-management, quality outcomes, and resource utilization goals.
• Identifies and refers patients for social worker intervention, as well as transitions of care follow up at home.   
• Addresses complex clinical situations efficiently, to avoid unnecessary delays in care.
• Obtains the support of the social worker for complex social issues, behavioral problems, home and family issues, placements, guardianship, hospice, palliative care referrals, drug and alcohol abuse, and violence. 

Utilization Management

• Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post-acute care needs daily.
• Coordinates with post-acute partners and facilities to ensure efficient care and patient-centered transitions.  

General Responsibilities

• Exhibits computer systems knowledge and proficiency as necessary to perform job functions.
• Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards.
• Performs other duties as assigned when appropriate.
• Adheres to HIPAA guidelines set forth in Clinic policies and procedures.

POSITION REQUIREMENTS:

Education/Certification/License: 

Minimum of an unencumbered license as a Registered Nurse in the state of Indiana.

Knowledge, Skills, and Abilities:

• Must have experience in case management or care management (Certified Case Manager preferred)
• Must have experience with Medicare/Medicaid
• Experience with multiple EHR/EMR systems
• Ability to work collegially with staff members from multiple offices
• Ability to manage multiple patients simultaneously
• Ability to build and maintain relationships with patients, families and client providers
• A background in geriatric care, family medicine and/or long-term care (skilled nursing, home health, hospice, public health, assisted living) highly preferred.
• A background and ability to work with populations with special needs
• Competence and experience with electronic charting
• Ability to multitask
• Excellent written and verbal communication skills.
• Self-directed with the ability to work independently and in groups
• Exceptional time management skills, with a high level of individual initiative
• Detail oriented with strong organizational, planning, and problem solving skills
• Can be depended upon to effectively plan and organize multiple assignments to ensure workload’s completion, yet flexible enough to handle changing schedules

Special Demands/Requirements:

Occasional, local travel may be required for off-site meetings.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.