Registered Nurse 1

Job Title:
RN/Case Manager
Location:
Cookeville, TN 38501 (Hybrid)
Duration:
6 Months Contract (With a possible extension)
Job Description:
The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:
Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc.
Collaborate with primary care nurse and providers
Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider
Coordinate or make aware of social services resources, i.E., housing, clothing, food, mental health services, etc.
Collaborate with other social workers to identify patient and community resources
Conduct case management activities
Work with hospitals for discharge planning, follow-up and education
Assist with obtaining patient records from hospitals
Assist in securing needed medical equipment through community partners
Conduct follow-up on care plans
Identify patients lost to follow-up or overdue for care and assist them in returning to care
May assist with specialty referral navigation
Schedule, coordinate, and track non-BCS specialist and imaging referrals
Assist with obtaining patient records from specialists and imaging centers
Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact information
Assist patient with applications for programs such as CoverRx and RxOutreach
May help with other regional primary care-based initiatives with a social work component
Documents in patients record, updates consults, and tags provider and/or clinical staff as necessary
Provide patient education or find appropriate education resources
Expectations may include:
Complete on boarding and orientation
Participate in regional office and primary care clinical meetings as requested
Attend provider meetings as requested
Attend Health Councils and other community meetings to build relationships with social service agencies and promote health Customer services
Identify barriers to care or assistance experienced by our patients and seek ways to address them
Tools and Equipment:
Personal Computer, Telephone, Fax Machine, Printer, Scanner, Copy Machine, Calculator, Personal Vehicle and Other office related equipment as required.