Registered HIV Nurse Case Manager

About the role

The Registered Nurse (RN) Case Manager is responsible for coordinating and managing the delivery of comprehensive, patient-centered care. This role ensures optimal patient outcomes by assessing, planning, implementing, and evaluating individualized care plans in collaboration with interdisciplinary teams, patients, and their families. The RN Case Manager serves as a liaison between healthcare providers, community resources, and patients, focusing on effective resource utilization , continuity of care, and patient advocacy. Primary Responsibilities Using the nursing process, triage patient concerns via telephone and provide nursing advice. Receive phone calls relating to appointments, urgent care, inpatient admissions, prescription refills and test results in accordance with clinic protocols and coordinate proper disposition of each. Performs direct patient care activities, including assessment, evaluation, and treatment. Obtain, review, verify and/or complete health care forms related to home health care, referrals, medical equipment and other patient/physician needs as appropriate . Assist with managed care authorization and complete insurance and medical forms for patients or assist patients in completing the forms. Maintains detailed, confidential medical records in accordance with established protocols. Maintain tracking dashboard for high-risk patients, identifying critical follow-up visits. Demonstrates proficiency in the use of the electronic medical record (EMR). Collaborate daily with physicians and clinical staff to maximize quality care. Communicate plan of care to patients including responding to telephone messages and facilitating medication refills under the physician's direction. Monitor patient care to ensure patients progress towards desired outcomes. Coordinate patient follow-up and ongoing clinical management. Coordinates patient discharge plan, follow-up, and ongoing clinical management post discharge. Facilitates patient discharges from the clinic including completion of discharge summaries. Participates in staff and team meetings. Assist with the fiscal management of annual budgets. Participates in quality improvement efforts for continued high quality care Knowledge - Skills - Abilities Strong leadership, team-building and decision-making capabilities are essential, as well as the ability to set priorities, identify and resolve problems, and delegate effectively and efficiently . Excellent communication, computer, and organizational skills needed to manage workflow, patients, patient families, physicians, and others under stressful conditions . The ability to assess and triage patients and to communicate clearly and logically both orally and in writing needed . Must demonstrate reliability and maintain confidentiality.