Overview:
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Ambulatory Chronic Care Manager (RN) is a member of the enterprise Ambulatory Care Management team and is accountable for improving the health outcomes for all patients, with a particular focus on patients in value-based/risk contracts. The Ambulatory Chronic Care Manager (RN) works as part of a multi-disciplinary team under the direction of the Ambulatory Care Management leadership. The Ambulatory Chronic Care Manager (RN) is responsible for performing nursing assessments, evaluations, screenings, and development of action plans to mediate gaps in clinical care. The role will participate in all components of care management including, but not limited to, management of care transitions, medication reconciliation/review, provide patient-centered education related to acute or chronic illnesses, evaluate for social determinants and barriers that impact care management, adhere to quality metrics, facilitate communication among providers, and advocate for the patient, family, and support system.
Responsibilities:
1. Demonstrates an understanding of care management, complex disease management, transitions of care, post-acute care options, and community management standards.
1.1 Outreaches to and enrolls patients in chronic care management programs, establishing a therapeutic relationship and managing the patient's engagement for the duration of the program.
1.2 Educates the patient, family or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made.
1.3 Facilitates communication and coordination between members of the healthcare team and the patient to minimize fragmentation in service.
1.4 Demonstrates the ability to evaluate care management data to identify trends, develop action plans, and program modification for improved patient outcomes.
1.5 Identifies changes in patient condition warranting interventions and refers appropriately.
2. Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team.
2.1 Participates in interdisciplinary team rounds to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
2.2 Demonstrates the ability to develop cooperative relationships with internal and external partners or departments to provide exemplary service and achieve goals.
2.3 Maintains objectivity in decision-making and utilizes facts to support decisions.
2.4 Assists in eliminating barriers to achieve integrated, efficient, and quality service.
2.5 Utilizes resources efficiently and effectively.
3. Demonstrates an understanding of clinical standards, quality performance goals, and expected outcomes.
3.1 Demonstrates application of evidence-based practice and clinical practice guidelines to care plans and patient interventions.
3.2 Develops knowledge of population health, health equity, value-based care concepts and their application to the goals and objectives of the role and the department.
3.3 Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.
3.4 Participates in continuing education to develop new knowledge and skills applicable to the role and function.
4. Performs other duties as required or requested.
Qualifications:
EDUCATION:
Minimum of a Baccalaureate degree in clinically related field. CT R.N. license required.
EXPERIENCE:
Minimum of 3 years of combined clinical experience in direct patient care and care coordination/case management in an acute, community, or post-acute provider or health plan.
SPECIAL SKILLS:
Motivational interviewing skills necessary. Excellent verbal and written communication skills. Excellent organizational skills and ability to handle multiple priorities. Ability to work in an independent role with minimal supervision. Functions as an integral team member and demonstrates flexibility in sharing responsibilities. Validated translation capability preferred. Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed.
ACCOUNTABILITY:
Adheres to communicated care management productivity metrics, including caseload, engagement volume, and time to closure. Adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, multidisciplinary care team referrals, and appropriate cases closed in a timely fashion.
COMPLEXITY:
In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic). Requires independent problem-solving skills in coordinating care across the continuum and within the health care system. Must embody principles of High Reliability including communicating effectively with peers and arcing up concerns, accountability, mentorship and practicing and accepting a questioning attitude, maintaining HIPPA regulations.
LICENSURE/CERTIFICATION:
RN Licensure in Connecticut required; Certified Case Manager (CCM) or accredited equivalent certification preferred.
SPECIAL WORKING CONDITIONS AND PHYSICAL DEMAND:
Role is primarily a remote work position with the ability and expectation to travel to onsite practice locations from time to time as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards.
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