About the Role:
This position is responsible for managing high-risk, chronic illness patients to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes.
Responsibilities:
- Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.
- Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
- Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients that are action-oriented.
- Evaluate the effectiveness of the plan in meeting established care goals; revise the plan as needed to reflect changing needs, issues and goals.
- Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
- Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
- Performs follow-up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission.
- Maintains EMR databases on care managed populations. Maintains accurate and timely documentation in the EMR.
- Reviews utilization and quality reports routinely and scans for gaps in care to identify patients needing additional support of care management.
- Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
- Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
Qualifications:
Minimum 3 years of professional level medical and care coordination experience. Experience working with electronic medical records is required. Ability to communicate effectively with providers and medical staff. Ability to be self-motivating and work independently. Computer skills- proficient to expert. Excellent written and oral communication and problem-solving skills.
Education Requirements:
- RN required.
- Proficiency in medication indications and side effects.
- Understanding of medical tests and requirements for tests to provide the patients with appropriate information.
