Manages targeted patient populations to achieve efficient and effective care delivery. This includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Coordinates with the Primary Care Physician (PCP) and functions as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care 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 giver, health education and referrals. 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.
Essential Job Functions:
Facilitation of Patient Centered Care
- Identifies, evaluates, engages and enrolls high risk patients of specified populations.
- Performs complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources.
- Based on assessment and in conjunction with patient/family/caregiver, 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.
- Facilitates and monitors implementation of Plan of Care.
- Coordinates patient/family/caregiver participation in Plan of Care and self-management.
- Uses knowledge of community resources to facilitate achievement of goals.
- Coordinates patient education to achieve Plan of Care using evidence-based methods such as teach back.
- Performs home visits as necessary to evaluate possible barriers to attainment of self-management goals and develops strategies to overcome barriers.
- Other duties as assigned.
Interdisciplinary Practice
- Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post-acute and home settings.
- Demonstrates expertise in case management and serves as resource to the interdisciplinary health care team.
- Integrates knowledge of external and internal regulatory requirements into the review and management of cases.
- Works in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care.
- Serves as bridge across the clinical setting and functions as patient's consistent point of contact.
- Facilitates referrals to other disciplines and internal health and community-based programs as appropriate to improve patient outcomes.
Evidence-Based Care
- Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-Process Metrics, NCQA, URAC and HEDIS) when coordinating and facilitating Plan of Care.
- Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice.
Measurement and Reporting
- Documents in the medical record as indicated and designated case management tool accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.
Other Job Functions:
- Must be able to perform any clinical or clerical duty as assigned skillfully.
- Must comply with all OSHA and HIPAA regulations.
- Must demonstrate strong verbal and communication skills.
- Must demonstrate the ability to handle stressful situations appropriately.
- Must be able to work flexible hours as needed.
- Understand, adhere to, and implement the Company’s policies and procedures.
- Provide excellent customer service skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
- Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
- Engage in excellent communication which includes listening attentively and speaking professionally.
- Participate in projects and other duties as assigned by Market Leadership.
- Demonstrate attention to detail and accuracy in work product.
- Set and complete challenging goals.
- Other duties as assigned.
Required Qualifications:
Bachelor’s Degree or professional certification/license and 2-4 years of experience with 2 years case management preferred.
Education/Licensure: Registered Nurse (RN) with active license in the state of Ohio– BSN required.
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