RN Case Manager - Care Ally

The South Bend Clinic; Bruceville-Eddy (TX); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Healthcare benefits

401(k) match

Tuition reimbursement

Paid volunteer time off

Parental leave

Job summary

The South Bend Clinic is seeking a skilled Registered Nurse to manage case management and care coordination across care teams. You will collaborate with physicians, nursing and support staff to develop and monitor patient care plans and ensure timely service delivery.

Ideal candidates have Indiana RN licensure and experience with Medicare/Medicaid, EHR systems, and strong multitasking abilities. This role involves occasional local travel and close collaboration within a physician-led network.

Qualifications

• Must have an unencumbered RN license in Indiana.
• Experience with case management or care management.
• Experience with Medicare/Medicaid and multiple EHR/EMR systems.

Responsibilities

• Assists in planning and implementing educational needs of patients with direct care team.
• Coordinates clinical care plans with Primary Care Provider and team, communicates with patient/family.
• Reviews services with patients and assists in CCM enrollment.
• Delivers services to execute electronic care plans.
• Assesses health and educational needs from calls and medical records review.
• Maintains patient communication at minimum 20 minutes monthly.
• Collaborates with providers to facilitate appropriate services.
• Reviews care plans and updates as needed.
• Educates patients about diseases, treatments, and therapies.

Skills

Case management

Medicare/Medicaid experience

EHR/EMR systems

Time management

Communication skills

Multitasking

Geriatric care

Independent work

Education

Indiana RN license

Tools

EMR/EHR systems

Job description

If you are a current Duly/SBC/QMG employee, please apply through the Internal Career Site.
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.

Education/Certification/License

POSITION REQUIREMENTS

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.

INDHP

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.