Provide case management for a panel of high acuity engaged patients with responsibility to develop, manage and coordinate a plan of care to include medical and/or psychosocial needs that address complex chronic conditions, social determinants of health, patient centered goals, and barriers of care to help maintain the person in their home whenever possible, ensure high quality and cost-effective care, and prevent unnecessary hospital based careUtilizes nursing assessment and evaluation skills to help guide treatment and care decisions of the teamIdentifies services and vendors for necessary care while navigating patient benefit plansWorks collaboratively with a multidisciplinary team of MDs/NPs/PAs, behavioral health clinicians, pharmacists, dietitians, social workers, primary care physicians and specialty physicians, as well as the patient, family and/or caregiver as they provide supportive care to enrolled patientsEnsures that medical services are managed in the most effective and appropriate health care setting according to the patient's current medical conditionResponsible for developing and implementing a plan of care appropriate to the patient's clinical condition and psychosocial needs to maximize his/her level of functioning- These plans are developed as a result of clinician, care manager and allied clinical support evaluation, as well as physical risk assessmentEstablishes and maintains communications with the responsible party of the memberIntegral member of local precepting team (OWL- Opportunity to Work and Lead) responsible for mentoring and training new hire RN case managersAssisted local market Outreach team with member engagement, as well as assisted with local TOC (Transitions of Care) program engagementFunctions as a liaison between Landmark and HIXNY (Healthcare Information Xchange of NY) to improve portal interface for changing company needsCollaborates with market leadership to manage daily market operationsServes as a subject matter

Fulfilled the role of charge nurse, ensuring adequate staffing, updating patient bed assignments and nursing assignments as neededCompleted weekly unit audits as lead CAUTI committee RNCompleted quarterly clinical fair education as well as attend mandatory educational in-servicesCoordinated consultations, services and treatments using Soarian computer systemProvided some aspects of personal care for medical-surgical population including administration of medication, monitoring vital signs, ensuring adequate I&O, and prevention of skin breakdown, as well as drawing routine and stat labs as neededCompleted patient teaching regarding medications, interventions, procedures and optimal outcomesCommunicated with interdisciplinary team regarding patient status, issues and/or concerns and update patient plan of care as necessary to reflect improvement or decline in status

Prepared patients for examination and treatment, perform laboratory work and EKGs if necessaryAssembled exam and treatment rooms with necessary instruments for treatmentAdministered injections and apply dressings as instructed, and distribute medications as directed by Physician, PA, or NPTriaged patients based on severity of illness and determine if further medical treatment is needed, documentation of all care rendered