POSITION STANDARDS Master's degree in nursing required. Licensed as a Registered Nurse in the State of New Hampshire. BCLS certification required within 30 days of hire. Board Certification in Case Management (CCM or CMC) preferred. If not certified, willingness to work toward CCM Certification in reasonable timeframe. Five years’ experience in a health care setting. Previous Experience as a Case Manager required. Excellent interpersonal skills required. Ability to build and maintain positive working relationships. Excellent written and verbal communication skills. Computer skills required. Capable of prioritizing and completing a high volume of requests quickly and efficiently in multiple diverse environments with strong attention to detail. Ability to work effectively in a self-directed role and make clear decisions. POSITION PHYSICAL REQUIREMENTS Anything listed here requires a pre-employment physical by Employee Health to determine if the employee is capable of meeting the requirements. Physical Activity: Upper Extremity: Push/Pull/Lift/Carry: PART TWO: FUNCTIONAL RESPONSIBILITY

 

Position Objective The Continuing Case Manager participates in the management of illness, striving to achieve measured clinical and psychosocial advancements across the patient’s healthcare continuum.

 

Performance Expectation Manages and coordinates interdisciplinary care of defined populations through the care continuum from a clinical, psychosocial and environmental perspective. Identifies high-risk patients requiring on-going coordination of care; completes a comprehensive patient/support system assessment, participates with the multidisciplinary team in developing a comprehensive treatment plan that will span the continuum of clinical and psychosocial issues and plan of care. Provides continuing support and coordination for patient/support system with multiple complex system needs, and manages and negotiates continuing care services for enrollees in various health insurance plans. Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in all areas including clinical. Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.). Shares assessment and clinical, psychosocial and environmental care plan data with patient/support system consent as the patient moves through different care settings. Identifies gaps in the care continuum and works with the community and provider networks to expand access to needed clinical, psychosocial and environmental services. Participates in the development of clinical disease management strategies and identifies the appropriate measures for the evaluation of outcomes. Participates in the development, maintenance, and coordination of a multidisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization. Collects and evaluates clinical and financial data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization. Performs other duties as required or assigned.