Location: Amsterdam, NY                     

FLSA: Exempt

Reports To: Assistant Director of NDHC          

Job Qualifications:

1. Registered Nurse with valid NYS RN license required.  
2. Basic life support and Bachelor’s Degree preferred. 
3. Minimum three years prior experience in case management required. 
4. Experience with Electronic Health Records preferred. 
5. Must be able to read and write the English Language.
6. COVID 19 Vaccination required prior to start of work. 

Major Responsibilities:

1. Assess patients’ needs and develop flexible service care plans and maintain regular updates of these care plans, as needed.  
2. Conduct comprehensive and ongoing risk assessments and engage patients in risk reduction and positive prevention discussions and activities.  
3. Perform program specific patient outreach, education, and recruitment.  
4. Address service needs and encourage engagement into systems as needed.  
5. Knowledge and maintenance of relationships with community, social, and health resources to ensure patient access.  
6. Work with primary care provider to initiate in person or telephone contact with eligible patients to perform initial assessment, healthcare education, develop realistic care management plan and establish treatment goals.  
7. Incorporate knowledge of case management, levels of care, and utilization management principles to implement high quality and cost-effective care.  
8. Utilize excellent interpersonal skills when communicating with patients, families, and clinicians to develop rapport, build trust, and engage patients in health promotion activities.  
9. Influence utilization of health care resources by providing direct care coordination to patients, encouraging enrollment in disease management programs (e.g., smoking cessation, hypertension, diabetes) follow-up after interaction with health care system, e.g., inpatient, ED visit, outpatient services, etc.  
10. Consistently and effectively utilize all steps of the nursing process in the provision of timely, safe, efficient, and appropriate patient/centered care.  
11. Conduct pre-visit chart review of patients to identify needs.  
12. Work with patients and families on Self-Management Support including: 
13. Setting short term and long-term goals for self-management of chronic disease. 
2. Provide or arrange needed patient education regarding specific health skills and general disease concepts.  
13. Participate in Clinics (Flu / Injections). 
14. Provide backup for Medical Assistant. 
15. Participate in staff/team meeting and activities. 
16. Organizational skills to multi-task, set priorities, and efficiently complete assigned work.  
17. Conduct and submit reports within required time frames.  
18. Maintain competency in areas of responsibility to ensure quality of care. 
19. Maintain patient confidentiality; comfortable handling sensitive personal information. 
20. Perform other duties as specified by supervisor.