Job Description
WHO WE ARE:
Aviva Health is a dynamic and mission-driven federally qualified health center (FQHC). Committed to providing comprehensive and compassionate healthcare services, Aviva Health offers a holistic approach to care, addressing patients' medical, behavioral health, dental, and social service needs. As a vital healthcare resource in the community, Aviva Health fosters a collaborative and supportive work environment where dedicated healthcare professionals have the opportunity to make a meaningful impact on the lives of individuals and families. Join us at Aviva Health and be part of a team that is dedicated to making a difference in the lives of our patients and the community we serve.
BENFITS INCLUDED:
- Monday - Friday Scheduling
- Paid Holidays
- PTO
- Comprehensive Medical, Dental, and Vision Coverage
- 403(b) Retirement with Employer Match
POSITION PURPOSE:
The primary function of the RN Case Manager is to work as part of the patient care team in providing high quality, efficient, and service-oriented patient care while demonstrating Aviva Health's core values. The RN Case Manager will work alongside physicians, advanced practitioners, clinic nurses and medical assistants to provide care coordination, medical and disease education to patients, and serves as a liaison between the patient and provider to resolve care concerns as they arise and carries out tasks as directed by medical providers. The RN Case Manager will participate in Quality Improvement, COVID-19 Case Management, Triage Services, Annual Wellness Visits, Chronic Care Management, Transition of Care, and Complex Case Management Model of Care programs.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Reviews patient history, medication list, diagnostics, and outside records to implement an appropriate plan of care for the patient as defined by the provider.
- Familiarity with the complex needs of a population with multiple medical, social, and psychosocial obstacles in achieving and maintaining wellness and stability.
- Explains procedures and treatments to patients and provides patient education on various health-related topics.
- Develops and implements patient care plans for high-risk patients by reviewing patient history, medication list, diagnostics, and outside medical records from other facilities.
- Communicates with providers, patients and family members regarding care plans, goals and expected outcomes.
- Communicate care plans with hospitals, skilled nursing facilities, home health agencies, pharmacies, and vendors, including scheduling and participating in case conferences.
- Ensures effective documentation in the EMR of activity such as test results, medication management, and adherence to follow-up appointments.
- Responds to patient telephone calls as needed.
- Coordinates transitions in care for patients (post-hospital discharges)
- Provides chronic care management based on standard nurse practices.
- Provides nursing assessment for patients with complex medical needs.
- Provides preventative health assessments in the form of annual wellness visits, medication review, nurse visits, etc.
- Completes point of care testing per nurse standing orders and communicates results with providers.
- Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
QUALIFICATIONS:
- Possession of current Oregon RN license in good standing.
- Possession of current CPR certification.
- Previous experience in Case Management required.
- Minimum of 1-3 years of clinical experience in a Clinical or Hospital setting.
- Disease Management in a clinical setting.
- Proficient computer skills including MS Word, Excel, PowerPoint, and Outlook.
- Previous experience with electronic medical records highly preferred.
- Able to multitask and work independently.
- Strong organizational and interpersonal skills.
- Excellent verbal and written communication skills.
Aviva Health is an Equal Opportunity Employer
We are committed to fostering a diverse and inclusive workplace where all qualified applicants receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, disability, veteran status, or any other legally protected status.
Aviva Health is a Drug-Free Workplace
To ensure a safe and secure environment for our employees and patients, Aviva Health maintains a drug-free workplace. All employment offers are contingent upon passing a drug screening and a criminal background check. Compliance with these policies is required throughout employment.
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