Katy Trail Community Health
  • Sedalia, MO, USA
  • Full Time

Katy  RN Case Manager will focus on improving the care provided to KTCH's patient population. Responsibilities include: coordination and management of the transitional care and chronic care management services. Identifying and resolving care gaps for routine and preventive medical services. Working directly with health insurance plans on the initiatives that improve the health outcomes for the KTCH patients enrolled in the health plans. Working effectively with care teams to assist with patient care and outcomes.

Responsibilities and Essential Functions:
Utilizes electronically generated reports to take action to remind patients or clinicians proactively of services needed including pre-visit planning, preventative care, chronic disease management, and reminders for specific tests.
Adds and Removes patients from the initiative per the PCHH guidelines
Carries out the transitional management services for ED follow-up and I/P discharges.
Conducts chronic condition management for individuals with target chronic conditions.
Conducts outreach through face to face follow-up, by telephone, secure portal, or postal mail to engage patients in their care.
Completes written care plans for all patients identified as falling within our three Important Conditions identified by the practice (they include diabetes, hypertension and hyperlipidemia) or other chronic conditions as identified.
Establishes self-management goal(s) with patients using self-management support concepts and motivational interviewing techniques.
Actively participates with community-based initiatives related to care management and transitions of care.
Conducts patient education regarding chronic conditions and importance of adhering to medications and evidence-based guidelines.
Utilizes resources within the facility or community to attempt to remove barriers and ensure positive patient outcomes.
Assess patient's readiness to change and self-management abilities
Completes written care plans for all patients as referred from the Medicaid Initiative.
Coordinates and communicates with health plans as appropriate.
Communicates with the health care team on a daily basis to identify opportunities to close gaps in care.
Maintain accurate records and provide reports on managed Medicare and Medicaid, Missouri Care, United Healthcare, and Home State.
Assists with provider and office staff education regarding health plan initiatives.
Works directly with the Population Health/QI Director to identify opportunities for continuous improvement, develops related plans of action and implements process and documentation improvements.
Demonstrates commitment to providing outstanding customer service in a manner that is reflective of the KTCH mission.
Provide education to patients, families, and other individuals providing care and/or services to the patient about managing their disease(s), conditions, and supplemental information as requested and/or needed.
Assist care teams by providing medication reconciliation, medication renewal, closing open care gaps, educating on preventative services, and scheduling follow up appointment.
Provide update on case management services and support at the Performance Improvement meeting.
Takes a leading role in the care team meetings. Discusses empanelment, cohorts, and collaborates with care team in assisting with barriers and providing high quality care to patients.
Demonstrate the ability to communicate effectively with all members of the healthcare team, patients, and community representatives.
Performs related duties as assigned.
Duties may change based on circumstance, including state of emergency reassignments.

Minimum Qualifications:
Possess high school diploma or equivalent.
Maintains valid, current RN licensure in the State of Missouri
A minimum of three (3) years' experience in a clinic setting
Experience in a community health center setting, preferred
Possess current CPR certification
Possess basic keyboard skills and computer knowledge.
Must demonstrate accuracy, proficiency and efficiency from approved training program.
Must be able to see, hear, read, write, kneel, stand, sit and lift up to 50 lbs.
Must be able to handle stressful situations.
Maintain professional appearance and attitude at all times.
Must maintain patient confidentiality at all times.
Must demonstrate tact, patience, and good communication skills in dealing with patients, staff, and the public.


Katy Trail Community Health
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