Nurse Case Manager Outpatient

Who We Are JPS Health Network is a $950 million, tax-supported healthcare system in North Texas. Licensed for 582 beds, the network features over 25 locations across Tarrant County, with John Peter Smith Hospital a Level I Trauma Center, Tarrant County's only psychiatric emergency center, and the largest hospital-based family medical residency program in the nation. The health network employs more than 7,200 people.

Acclaim Multispecialty Group is the medical practice group featuring over 300 providers serving JPS Health Network. Specialties range from primary care to general surgery and trauma. The Acclaim Multispecialty Group formed around a common set of incentives and expectations supporting the operational, financial, and clinical performance

outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

Why JPS? We're more than a hospital. We're 7,200 of the most dedicated people you could ever meet. Our goal is to make sure the people of our community get the care they need and deserve. As community stewards, we abide by three Rules of the Road :

1. Own it. Everyone who wears the JPS badge contributes to our journey to excellence.

2. Seek joy. Every day, every shift, we celebrate our patients, smile, and emphasize positivity.

3. Don't be a jerk. Everyone is treated with courtesy and respect. Smiling, laughter, compassion - key components of our everyday experience at JPS.

When working here, you're surrounded by passion, diversity, and dedication. We look forward to meeting you!

For more information, visit www.jpshealthnet.org.

To view all job vacancies, visit www.jpshealthnet.org, www.jpshealthnet.org / careers, or www.teamacclaim.org.

Job Title :

Nurse Case Manager Outpatient

Requisition Number : 43083

Employment Type : Full Time

Division :

MED STUDENTS & EDUCATION

Compensation Type : Hourly

Job Category :

Business / Professional

Hours Worked : 8am-5pm

Location :

John Peter Smith Hospital

Shift Worked : Day

Job Description :

Job Summary : The Nurse Case Manager Outpatient provides guidance and direction and acts as a resource to department team members to enhance patient care. The Nurse Case Manager Outpatient is responsible for providing care management services and support to an assigned population with the purpose of improving patient health outcomes via a coordinated approach. The Nurse Case Manager Outpatient works in continuous partnership with patients and their family members, as well as clinic, hospital and post-acute partners, along with community based organizations, to achieve the desired outcomes. Using a defined process, the Nurse Case Manager Outpatient, identifies patients through risk stratification, establishes care plans and goals and coordinates care and services through the continuum of care with the goal of enhancing patient health, improving adherence to health programs and reducing health care costs. This position integrates population management, care transition, utilization and quality management functions to enhance the quality of clinical outcomes and patient satisfaction while achieving the desired financial and resource utilization outcomes

Essential Job Functions & Accountabilities :

• In conjunction with data analytic tools, payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination including but not limited to, preventive health care, disease management, behavioral health screenings and interventions, care opportunities, etc.
• Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-cost, high-need, high-utilizing population, and collaborates with clinical staff and the patient / family in the development and execution of the plan of care, and achievement of goals.
• Manages and supports the assigned population with moderate to complex care needs throughout a defined episode of care.
• Aids patient navigation through the care continuum with the goal of preventing and / or reducing readmissions, admissions, avoidable ED visits and ensuring that care is provided the right time, place, person and location.
• Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health, dieticians and specialists in order to provide ongoing care coordination.
• Provides care management services to assigned patients telephonically and face to face. Travel as needed to provider offices, hospitals, patient homes and post-acute settings may be required. Local travel may be required to perform duties at multiple sites.
• Manages effective transitions in care by facilitating warm hand offs with various interdisciplinary team members, physicians and community partners.
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Assists patients with medication management and compliance, including a medication review, and makes referrals to other care team members such as a pharmacist to promote medication adherence.
• Provides education and coaching regarding chronic disease / s, self-management, community resources, etc. to support and empower patients to take a more proactive role in managing their health, well-being and shared decision making.
• Job description is not an all-inclusive list of duties and may be subject to change with or without notice. Staff are expected to perform other duties as assigned.

Qualifications :

Required Qualifications :

Preferred Qualifications :

Location Address : 1500 S. Main Street

Fort Worth, Texas, 76104

United States