JOB DESCRIPTION FOR JOB TITLE:



|Nurse Case Manager- UW Health Patient Resources |

|Job Code: 800023 |FLSA Status: Exempt |

|Mgt. Approval: Date: |HR Approval: DPS Date: 6-13 |

|JOB SUMMARY |

|Under the supervision of the Nurse Manager, Complex Case Management, the Nurse Case Manager is responsible for intake and providing case management services for the |

|medically and/or socially complex patients/families who are medically homed within UW Health. The patient/family population covered will include significantly complex |

|medical conditions, and/or social-economic and mental health co-morbidities. The goal of the program will be to assist these patients and families to achieve optimal |

|health and/or independence in managing their care. To achieve this goal the manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive |

|case management, patient/family-centered, culturally sensitive care coordination and management of complex patients and families. |

| |

|The case manager will be responsible to develop plans for patient and family self-care competence, including motivational assessment, assessing for desired level of |

|involvement and coaching for adherence to care plan. S/he will provide nursing assessment, create and monitor patient/family care plans, including end of life |

|planning. In addition, the manager performs care within delegation protocols for select disease management conditions, including medication titration and test |

|ordering. The primary contact with the patient, family and other involved care providers will be by telephone, electronic medical record (EMR) patient portal and |

|other telehealth methods. The role may include home assessment and/or meeting patient at medical appointments for some patients, within a 50 mile radius of Madison, |

|Wisconsin. |

| |

|The case manager promotes knowledge of this program throughout UW Health, additional hospitals and programs where UW Health medically homed patients live and receive |

|care. In addition, s/he is responsible to create and sustain partnerships with community resources and support agencies. |

|MAJOR RESPONSIBILITIES |

| |

|CLINICAL CASE MANAGEMENT |

|A. Assessment |

|1. Conducts a comprehensive patient/family assessment upon admission and at regular |

|intervals as requested to initiate and maintain the patient plan of care. |

|2. Reviews patient’s record to determine health status and risk factors. |

|3. Identifies patient/family education needs and ensures that patient/family members |

|have adequate information to participate in care planning and that they are given |

|choices in the process. |

|4. Assessment may take place in the patient’s home on occasion and at medical visits throughout UW Health clinics and inpatient settings. |

| |

|B. Analysis |

|1. Demonstrates ability for complex clinical decision making. |

|2. Critically evaluates and analyzes physical and psychosocial assessment data. |

|3. Differentiates between normal and abnormal physical findings and adaptive and |

|maladaptive behavior. |

|4. Evaluates developmental status and mental status and utilizes data to modify plan of |

|care. |

| |

|C. Care planning |

|1. Initiates and maintains communication and collaboration with physicians, care |

|team leaders, staff nurses, other care giving disciplines and patients/families to develop, implement, and |

|evaluate a plan of care for each patient within the assigned clinical service. |

| |

|D. Intervention |

|1. Provides patient and family education and counseling about existing health problems and related care. |

|2. Acts as a clinical expert resource to others involved in care in planning and implementing comprehensive |

|care. |

|3. Utilizes financial and insurance resources of the patients to maximize the health |

|care benefit to the patient. |

| |

|E. Evaluation |

|1. Monitors the achievement of clinical outcomes. Assists the patient and family as necessary to modify |

|the plan of care. |

|2. Arranges referrals for patients with health problems requiring further evaluation |

|and/or additional services. |

|3. Provides follow-up with patients and families |

|4. Advocates for patients and families within the health care system. |

|5. Participates in peer review of clinical practice. |

| |

|II. LEADERSHIP |

| |

|A. Coordinate and facilitate patient progression throughout the continuum. |

|1. Collaborate with all members of the interdisciplinary team to facilitate the care coordination and |

|care delivery. |

|2. Monitor patient’s progress, intervening as indicated to ensure the plan of care and services |

|provided are patient focused, high quality, efficient, and cost effective. |

|3. Identify and facilitate resolution of system process problems impeding diagnostic or treatment |

|progress. Identify and resolve delays and obstacles to discharge. |

|4. Meets with patients/families to assess needs and develop an individualized care plan, |

|collaborating and communicating with interdisciplinary team in all phases of the care plan. |

| |

|B. Collaborates with all members of the healthcare team and external customers. |

|1. Provides clinical consultation to physicians and UW Health System staff on case management |

|issues. |

|2 Interacts with physicians in a timely, positive manner to resolve case management issues. |

|3. Seeks consultation from appropriate disciplines/departments as required to expedite care. |

|4. Refers appropriate patients to Complex Case Management Social Work for psychosocial intervention, guardianship, and financial in a timely manner. |

| |

|D. Participates in clinical performance improvement activities to achieve set goals. |

|1. Uses data to drive decisions and plan/implement performance improvement strategies related to |

|clinical care coordination of patients. |

| |

|E. Demonstrates positive and professional written, verbal and nonverbal communication skills. |

| |

|1. Substantiate activity by documentation that is entered in a clear, concise, organized, and |

|timely manner. |

|2. Demonstrate professionalism and good interpersonal skills in communicating with all customers. |

|3. Utilizes negotiation skills, which effectively promote constructive solutions. |

|4. Utilizes appropriate communication style and techniques. |

|5. Reflects concise clinical pertinence in documentation for assigned patient population. |

|6. Documents case management, quality, and risk concerns and refers to appropriate departments as |

|applicable for follow up. |

| |

|F. Applies advanced critical thinking and conflict resolution skills using creative approaches. |

|1. Identifies creative approaches and takes appropriate action as indicated. |

|2. Uses critical thinking and problem solving skills effectively. |

|3. Demonstrates a working knowledge of regulatory standards |

|4. Demonstrates a working knowledge of disease and age specific impact. |

| |

|III. EDUCATION |

| |

|A. Participates in the orientation of new department staff. |

|B. As requested, will provide learning opportunities for students in various health care disciplines. |

| |

|IV. RESEARCH |

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|A. Participates in organizational improvement activities. |

|B. Identifies recurring clinical practice issues and contributes to the development of specific |

|plans to address identified issues. |

|C. Demonstrates knowledge of research findings related to clinical specialty. |

|D. Participates in activities that support the advancement of case management, utilization review, |

|and discharge planning through literature review, professional organizations, research, |

|committee participations, etc. |

|E. Consistently uses new knowledge, technology and research in practice. |

| |

|V. PROFESSIONAL DEVELOPMENT/EFFECTIVENESS |

| |

|A. Enhances professional and departmental growth through active participation in professional |

|organizations, department activities, and community groups. |

| |

|1. Provide educational offerings in area of expertise at UWHealth its affiliates and in the community. |

|2. Monitor and improve quality of services provided to patients/families through ongoing |

|participation in unit and Departmental PI activities. |

|3. Apply principles of interdisciplinary teamwork and maintain a working knowledge of other |

|healthcare professional’s roles. Respect other professions and seek opportunities for |

|collaboration. |

|4. Meets individual goals set during annual performance review. Establishes an ongoing work plan |

|with quarterly updates. Solicit and apply appropriate feedback to individual performance. |

| |

| |

|ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS. |

|JOB REQUIREMENTS |

|Education |Minimum |Bachelor’s degree in Nursing or ADN with 5 years of case management experience and BSN completion within 5 |

| | |years of hire required |

| |Preferred | |

|Work Experience |Minimum |Two (2) years RN experience required |

| |Preferred |Clinical experience in nursing care of the medically complex patient |

|Licenses & Certifications |Minimum |Maintain state RN licensure in state where employed |

| | |Maintain CPR certification |

| | |Case Management Certification; or must be obtained within three (3) years of hire and maintained during |

| | |employment. |

| | |Valid Wisconsin driver’s license and current auto insurance. |

| |Preferred | |

|Required Skills, Knowledge, and Abilities |Knowledge and skill in chronic disease management |

| | |

| |Excellent verbal and written communication (including documentation) skills |

| |Excellent relationship management with patients, families, and care providers |

| | |

| |Professional demeanor |

| |Ability to work with patients in multiple environments (homes, clinics) |

| |Flexible in trying new things while developing a new care program |

| | |

| |Ability to work as a member of a team |

| | |

| |Ability to organize and prioritize tasks |

| |Ability to promote/participate in patient centered medical home mode of care |

| | |

| |Exceptional customer service skills and understanding of patient and family centered care concepts |

| | |

| |Strong organizational skills |

| | |

| |Proficient in Microsoft Office |

| |Electronic Medical Record (EMR) experience preferred |

| |Change-agent, embraces new technology |

| |Self-directed |

| | |

|AGE SPECIFIC COMPETENCY (Clinical jobs only) |

|Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients. |

|Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, |

| |Infants (Birth – 11 months) |X |Adolescent (13 – 19 years) |

|X |Toddlers (1 – 3 years) |X |Young Adult (20 – 40 years) |

|X |Preschool (4 – 5 years) |X |Middle Adult (41 – 65 years) |

|X |School Age (6 – 12 years) |X |Older Adult (Over 65 years) |

|JOB FUNCTION |

|Review the employee’s job description and identify each essential function that is performed differently based on the age group of the patient. |

| |

|PHYSICAL REQUIREMENTS |

|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals with |

|disabilities to perform the essential functions of this position. |

|Physical Demand Level |Occasional |Frequent |Constant |

| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |

|X |Sedentary: Ability to lift up to 10 pounds maximum and occasionally |Up to 10# |Negligible |Negligible |

| |lifting and/or carrying such articles as dockets, ledgers and small | | | |

| |tools. Although a sedentary job is defined as one, which involves | | | |

| |sitting, a certain amount of walking and standing is often necessary | | | |

| |in carrying out job duties. Jobs are sedentary if walking and | | | |

| |standing are required only occasionally and other sedentary criteria | | | |

| |are met. | | | |

| |Light: Ability to lift up to 20 pounds maximum with frequent lifting |Up to 20# |Up to 10# or requires |Negligible or constant |

| |and/or carrying of objects weighing up to 10 pounds. Even though the | |significant walking or |push/pull of items of |

| |weight lifted may only be a negligible amount, a job is in this | |standing, or requires |negligible weight |

| |category when it requires walking or standing to a significant degree.| |pushing/pulling of arm/leg | |

| | | |controls | |

| |Medium: Ability to lift up to 50 pounds maximum with frequent |20-50# |10-25# |Negligible-10# |

| |lifting/and or carrying objects weighing up to 25 pounds. | | | |

| |Heavy: Ability to lift up to 100 pounds maximum with frequent lifting |50-100# |25-50# |10-20# |

| |and/or carrying objects weighing up to 50 pounds. | | | |

| |Very Heavy: Ability to lift over 100 pounds with frequent lifting |Over 100# |Over 50# |Over 20# |

| |and/or carrying objects weighing over 50 pounds. | | | |

|List any other physical requirements or bona fide occupational qualifications:| |

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