Purpose of Position
The RN Patient Advocacy and Case manager coordinates and manages healthcare services to improve health outcomes and the patient experience within the Patient-Centered Medical Home (PCMH) framework.

Description
1. Works collaboratively with PCMH providers to facilitate coordination of care and access to resources for patients within the practice and external entities such as therapists, schools, social service agencies, and courts, staying up to date on behavioral health services and practice requirements. Locates outside specialty services for patients when needed.
2. Assists with patient screenings and evaluates social needs using approved screening tools and identifies appropriate resources based on screening results.
3. Participates in patient care team meetings to contribute to determining appropriate patient care services. Ensures multidisciplinary treatment plans align with patient and family needs.
4. Assists with tracking referrals, labs, and imaging to ensure timely completion and contacts patients for reminders and notifies them of results upon provider request.
5. Coordinates with external facilities for result and consult note retrieval.
6. Identifies and monitors high-risk patients and collaborates with providers, patients, and caregivers to manage high-risk or complex cases.
7. Assists in creating, implementing and maintaining patient-centered care plans, setting goals with patients and coordinates patient discharge when goals are met.
8. Educates patients and caregivers during teaching encounters to enhance health literacy and promote active engagement in healthcare and chronic disease management.
9. Assesses patient needs and eligibility for services and facilitates referrals to community agencies for a seamless transfer of patients to other agencies.
10. Communicates clearly and effectively with individuals of varying educational levels, backgrounds, and cognitive levels.
11. Ensures accurate record maintenance and collaborates with PCMH providers, patients, and caregivers.
12. Advocates for patients by developing effective partnerships with patients, families, and treatment teams.
13. Identifies behavioral health services and resources within the community.
14. Performs other related duties as assigned or requested, displaying flexibility, cooperation, and team-oriented characteristics.
15. Assists in providing clinical care to office patients under the direct supervision of the clinician, department supervisor, or designee.
16. Greets and escorts patients to exam rooms, obtains relevant information, takes vital signs, and performs medication reconciliation.
17. Demonstrates knowledge of community resources and acts as a resource to other staff for comprehensive referrals and services.
18. Consistently provides service excellence to all patients, family members, visitors, volunteers, and co-workers.
19. Challenges current working practices, identifies process improvement opportunities and presents recommendations and solutions to management.
20. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.

Qualifications
Ability to read, write, and communicate in English
· Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
· Bachelor of Science Degree in Nursing preferred (external applicants)
· Basic Life Support Certification for Health Care Providers
· Experience with current office technology and proficiency with computer office applications (Electronic Medical/Health Records, MS Office, etc.)
· Minimum of 2 years' experience in an outpatient setting, preferably in a PCMH setting
· Strong interpersonal and communication skills demonstrated by a positive attitude, and pleasant, professional, and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies