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Job Summary
Manages targeted patient populations to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites, including inpatient, ambulatory and patient home settings. Ensures continuity of care through defined, evidence based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care givers, education and referrals. Develops care plan and collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources.
Accountabilities
Facilitation of Patient Centered Care
1. Identifies, evaluates and enrolls high risk members of specified populations.
2. Performs complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources
2. Based on assessment and in conjunction with patient/family, Provider and other healthcare team members, participates in the development of an initial Plan of Care and Self-Management Plan that highlight actual and potential opportunities for improving clinical outcomes and/or utilization patterns and decreasing gaps in care.
2. Facilitates and monitors implementation of Plan of Care.
3. Coordinates patient/family participation in Plan of Care and self management.
4. Uses knowledge of community resources to facilitate achievement of goals.
5. Coordinates patient education to achieve Plan of Care using evidence based methods such as teach back.
6. Performs home visits as necessary to evaluate possible barriers to attainment of self management goals and develops strategies to overcome barriers. 35%
Interdisciplinary Practice
1. Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post acute and home settings.
2. Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team.
3. Integrates knowledge of external and internal regulatory requirements into the review and management of cases.
4. Works in collaboration with inpatient and ambulatory Prisma Health staff, as well as non Prisma Health staff as necessary to facilitate continuity of care.
5. Serves as bridge across the clinical setting and functions as patient's consistent point of contact
6. Facilitates referrals to other disciplines and internal and community based programs as appropriate to improve patient outcomes. 35%
Evidence Based Care
1. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRS, NCQA, URAC and HEDIS) when coordinating and facilitating Plan of Care.
2. Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice. 20%
Measurements and Reporting
1. Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals. 10%
Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Education Bachelor's degree - Nursing
Minimum Experience 3 years total nursing experience with at least 1 year Care Management/Case Coordination preferred.
Required Certifications/Registrations/Licenses South Carolina recognized R.N. License (Lawson Code NLRN) SOUTH CAROLINA DRIVERS LICENSE (Lawson Code LSCD)
In lieu of the Above Minimum Requirements In lieu of the BSN requirement above, an Associate's Degree in Nursing may be accepted if the applicant agrees to enroll in an accredited BSN or MSN program within one (1) year of their job effective date and obtain a BSN or MSN degree within four (4) years of their job effective date. This in lieu of is only applicable to current employees of Prisma Health or its affiliated companies.
Other Required Experience Proof of current auto liability coverage - required Must be willing to travel and have reliable personal transportation - required Obtain case management certification (CCM) within 2 years of hire or eligibility to sit for the certification exam - Required As of July 1, 2018, incumbents without a BSN or MSN will have a grace period of one (1) year to enroll in an accredited BSN or MSN program and four (4) years to obtain a BSN or MSN from an accredited program. To remain qualified for this position, incumbents must demonstrate continued enrollment and progress in an accredited nursing program until a BSN or MSN is conferred - required
Work Shift
Location
Greenville Memorial Med Campus
Facility
7002 Value-Based Care and Network Services
Department
Care Transformation
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