Home Therapy Nurse Case Manager

Fresenius Medical Care · San Antonio

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PURPOSE AND SCOPE:

Promotes quality patient care, ongoing customer support and case management for Fresenius Kidney Care (FKC) renal patient population (internal and external) by providing guidance, support, care coordination, education and other case management functions as defined by the pertinent program. Manages the implementation of the pertinent program as assigned while acting as the subject matter expert and resource for patients, dialysis staff, physicians and other healthcare professionals.

Services are generally provided telephonically but there may be programs where on-site visits to clinics, medical office, hospital or visits to patient homes are required. Programs include but are not limited to the Patient Onboarding, Continuity of Care, Hepatitis C Nurse Advocates and Anemia Case Management programs. Will support FMS’s mission, vision, core values and customer service philosophy.

Adheres to the FMS Compliance Program, including following all regulatory and FMS policy requirements.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program.
• Adheres to company, department, program policies and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs.
• Collaborates with the clinical staff, physicians and other members of the patient’s healthcare team, to develop an individualized and comprehensive plan of care according to the applicable program specifications.
• Ensures the coordination and integration of services as planned in the pertinent program while revising the plan as needed to provide high quality continuity of services and cost-effective service delivery.
• Utilizing the telephone and other technical and electronic communication formats to remotely monitor the care of the patient according to the program requirements. There may be situations within the pertinent programs which require the case manager to meet the patient, the patient’s family and/or the physician face to face in the home, clinic or medical office setting.
  • Proactively contacts the patient and/or clinic on a frequent basis as specified in the program details to assess their situation, provide assistance, and answer questions as necessary.
  • Revises and adjusts the patient care plan as needed to fit the needs of the patient. Provides updates to clinical staff, physician and/or family members as detailed in the program documents.
  • Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation. Provides the appropriate education, support and materials to facilitate informed decision making and understanding.
  • Provides a strong and effective reciprocal communication process with patients (in applicable programs), clinic staff, physicians and extended care team to ensure all issues and concerns regarding each specific program are addressed and resolved.
• Assesses patient conditions, in conjunction with clinic staff, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention.
• Maintains and updates the appropriate software/tracking logs of patients in the program to manage and record required information and data. Generates and analyzes reports as needed for management, identifying trends, anomalies and areas of concern.
• Evaluates program processes, identifying options to increase efficiencies and effectiveness of program. Make recommendations to management and assist with implementation as appropriate.
• Complies with departmental and program quality standards and quality assessment and performance improvement requirements.
• Maintains integrity of Protected Health Information (PHI).
• Complies with all company and departmental required data collections and auditing activities.
• Act as a resource for the customer to address concerns and questions.
• Participates in process improvement activities.
• Monitors and reinforces FKC quality goals and the elements of the case management program.
• Participates in project-based assignments.
• Maintains current knowledge of the departmental program software and the company’s clinical information systems.
• Other duties as assigned.

Additional responsibilities may include focus on one or more departments or locations.  See applicable addendum for department or location specific functions.

PHYSICAL DEMANDS AND WORKING CONDITIONS:

• The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The majority of the day is spent working at a desk. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Travel and visits to clinics, patient homes, and physicians’ offices may be required by program. See program specific job addendums.

EDUCATION:

• RN required with active unrestricted nursing licensure in practicing state – with the ability to obtain licensure in multiple states.
• BSN preferred.

EXPERIENCE AND REQUIRED SKILLS:      

• 0 – 2 years’ of Nephrology Nursing and/or case management experience.
• Experience in a role related to patient education and/or case management is preferred.
• Certified Case Manager (CCM), preferred.
• Must exhibit leadership skills and be able to collaborate with clinic staff.
• Must have knowledge of teaching-learning process, principles, and methods of adult education.
• Understanding of renal and diabetes disease process and current management practices.
• Excellent written and verbal communication is necessary.
• Excellent and professional telephone skills.
• Ability to function as a part of an integrated team.
• Ability to develop positive relationships with patients, families, physicians, staff and other disciplines.
• Must be self-motivated, organized and able to plan a diversity of activities, and work independently.
• Able to follow oral and written communication, as well as, communicate information to individuals or groups with varying levels of education.
• Must exhibit practical computer skills, including experience using Microsoft Office.. PowerPoint skills are preferred. Proficient to advanced typing skills.

Fresenius Medical Care maintains a drug-free workplace in accordance with applicable federal and state laws.

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