Lead RN Case Manager

Description

Position Summary

The Lead RN Case Manager is responsible for coordinating care and managing patients with chronic health conditions in support of the Patient-Centered Medical Home (PCMH) model. This position promotes patient education, self-management, care coordination, and timely access to healthcare services to improve quality outcomes and reduce barriers to care. The Lead RN Case Manager collaborates with providers, clinical staff, community partners, and patients to ensure comprehensive, patient-centered care while supporting the vision, mission, goals, and objectives of Family Healthcare of Hagerstown.

In addition to direct case management responsibilities, the Lead RN Case Manager serves as a clinical resource and support person for clinical support staff. Lead responsibilities include coordinating workflow, providing day-to-day guidance, assisting with problem-solving, supporting process improvement initiatives, and performing other lead duties as assigned by the supervisor.

Responsibilities and Duties

Case Management and Care Coordination

• Coordinate care for patients with chronic and complex medical conditions utilizing Patient-Centered Medical Home (PCMH) principles.
• Identify patients appropriate for case management services in collaboration with providers and clinical staff.
• Conduct initial and ongoing patient assessments to identify healthcare needs, barriers to care, and opportunities for intervention.
• Develop, implement, monitor, and update individualized care management plans.
• Promote patient self-management through education, coaching, and reinforcement of treatment goals.
• Ensure patients receive appropriate preventive services, recommended screenings, laboratory testing, and follow-up care.
• Monitor and document patient progress, outcomes, interventions, and care plans within the Electronic Health Record (EHR).
• Maintain accurate documentation and case management records within established timeframes.
• Coordinate care among providers, specialists, hospitals, home health agencies, behavioral health professionals, and community resources.
• Assist patients and families in accessing community programs and services to address social determinants of health and barriers to care.
• Collaborate with the Community Outreach Worker and other support staff to improve care access and patient engagement.
• Conduct outreach to patients who miss appointments or require additional follow-up.
• Provide education and support to high-risk patients to encourage treatment compliance and improved health outcomes.
• Assist with triage coverage, including assessing patient needs and determining appropriate disposition and scheduling recommendations.
• Support care coordination activities for all Family Healthcare of Hagerstown service lines, including medical, dental, behavioral health, and mobile health programs.
• Assist with medication voucher program administration, tracking, reporting, and reconciliation activities.
• Maintain required patient care databases and quality reporting information.

Leadership Responsibilities

• Serve as a clinical resource and mentor for clinical support staff.
• Provide day-to-day guidance and support to team members.
• Assist with workflow coordination and continuous process improvement efforts.
• Support implementation of organizational initiatives, quality improvement projects, and department goals.
• Assist leadership with data collection, reporting, grant-related metrics, and special projects as assigned.
• Promote teamwork, accountability, professionalism, and effective communication throughout the department.
• Support compliance with clinical, regulatory, and organizational standards.
• Assist in maintaining Automated External Defibrillators (AEDs) and related documentation throughout the organization.
• Perform additional lead responsibilities as assigned by supervision.

Professionalism and Quality

• Maintain strict confidentiality of patient, employee, and organizational information.
• Demonstrate professionalism and a commitment to ongoing learning and professional growth.
• Foster respectful and collaborative relationships with patients, families, staff, volunteers, and community partners.
• Participate in quality improvement, patient safety, and risk management activities.
• Follow all Family Healthcare of Hagerstown policies, procedures, and applicable nursing standards.
• Perform other duties as assigned.

Benefits

Generous benefits package including accrued paid time off, seven (7) paid holidays, and one Anniversary Award after the first year of employment. Eligible employees may elect health, vision, and dental coverage (employee only, employee and child, employee and spouse, parent and child, or family plans). Additional benefits include company-paid Life and AD&D insurance, Short-Term and Long-Term Disability coverage, Employee Assistance Program (EAP), and a 403(b) retirement plan with company match. Voluntary benefits include cancer, hospital indemnity, accident coverage, and more.

Requirements

Position Qualifications

Education

• Graduate of an accredited Registered Nursing program required.
• Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred.

Experience

• Previous case management experience preferred.
• Previous experience in family practice, primary care, population health, care coordination, or community health preferred.
• Experience working within a Patient-Centered Medical Home (PCMH) model preferred.
• Proficient computer skills required, including electronic health records, Microsoft Office applications, and healthcare technology systems.
• Ability to efficiently document and manage patient information within the EHR.

Licensure/Certifications

• Current Registered Nurse (RN) license in the State of Maryland required.
• Current Basic Life Support (BLS) certification required.

Other Requirements

• Strong clinical assessment and care coordination skills.
• Knowledge of chronic disease management and patient education principles.
• Excellent communication, interpersonal, and organizational skills.
• Ability to work independently while collaborating effectively within a multidisciplinary team.
• Ability to maintain professional relationships with patients, families, staff, providers, and community organizations.

Physical and Mental Effort

Physical:

Moderate physical effort is required. Position involves prolonged periods of sitting, standing, walking, bending, reaching, and use of computer equipment. Requires manual dexterity for documentation, patient assessments, and use of clinical equipment. Ability to lift, carry, push, and pull up to 25 pounds occasionally. Duties may require movement between clinical departments and patient care areas throughout the workday. Normal vision and hearing, with or without reasonable accommodation, are required to safely perform job responsibilities.

Mental:

Frequent periods of concentration, clinical judgment, critical thinking, and attention to detail are required while managing patient care plans, coordinating services, reviewing medical records, and documenting patient interactions. The position requires the ability to prioritize multiple responsibilities, manage interruptions, solve problems independently, and respond effectively to changing patient needs. Frequent communication with patients, providers, community agencies, and staff requires strong interpersonal skills and professionalism.

Sensory:

Must be able to effectively communicate in spoken English and possess the ability to read, write, and comprehend English. Requires visual acuity sufficient to review medical records, assess patient information, utilize healthcare technology, and perform essential job functions safely and accurately.

Environmental and Working Conditions

Work is performed in a modern, well-equipped healthcare clinic environment. Daily interaction with patients, family members, providers, staff members, community agencies, and external healthcare organizations is required. Frequent use of computers, telephones, electronic health records, and other office and clinical technology is expected.

Potential exposure to bloodborne pathogens, infectious diseases, bodily fluids, and other healthcare-related hazards may occur. Employees are required to utilize appropriate personal protective equipment (PPE) and adhere to all infection control, OSHA, CDC, and organizational safety standards.

The position may involve frequent telephone communication, care coordination activities, patient outreach, and management of complex patient situations requiring sound judgment and decision-making. Adherence to patient confidentiality, workplace safety, and professional nursing standards is required at all times.