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Location

South Bend, IN | United States

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Job description

Overview

Location:

Eddy Street Campus

211 N Eddy Street

South Bend, IN 46617

Department:

Value Based Care Operations

Responsibilities

The Journeys and Adventures that Await

Patient Care / Patient Education

• Assumes an active role in the planning and implementing educational needs of assigned patients, with direct care team and need consultants: Diabetic Educator, pharmacy, dietary, wound care, etc.
• Coordinates assigned patients' clinical care plan in conjunction with the Primary Care Provider and with appropriate team members and communicates the plan to patient/family in a timely manner.
• Review services with interested patients and assist in enrolling them in the CCM program
• Provide all services necessary in order to execute an electronic care plan
• Determine an individual's health and educational needs as a result of inbound and outbound phone calls, and review of medical records with patients
• Maintain communication with patients to measure no less than 20 minutes per month
• Collaborate with the patient's provider to facilitate appropriate physical, behavioral and social services
• Review care plans and make changes as necessary
• Provide patients with information regarding medical questions/concerns
• Examples of CM activities may include educating newly diagnosed patients about the disease and treatments; managing therapies; and drug administration and side effects

Care Facilitation

• Develops, manages, and drives clinical plan of care with physician and multi-disciplinary care team.
• Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure timely patient management and facilitation of services.
• Coordinates patient care across the care continuum to reduce fragmentation of care and addresses/ resolve system issues that may be impeding progress and quality of care for patients.
• Focuses on management of the complex patient with the goal of patient self-management, quality outcomes, and resource utilization goals.
• Identifies and refers patients for social worker intervention, as well as transitions of care follow up at home.
• Addresses complex clinical situations efficiently, to avoid unnecessary delays in care.
• Obtains the support of the social worker for complex social issues, behavioral problems, home and family issues, placements, guardianship, hospice, palliative care referrals, drug and alcohol abuse, and violence.

Utilization Management

• Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post-acute care needs daily.
• Coordinates with post-acute partners and facilities to ensure efficient care and patient-centered transitions.

General Responsibilities

• Exhibits computer systems knowledge and proficiency as necessary to perform job functions.
• Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards.
• Performs other duties as assigned when appropriate.
• Adheres to HIPAA guidelines set forth in Clinic policies and procedures.

Qualifications

The Experiences You Bring

Education/Certification/License:

Minimum of an unencumbered license as a Registered Nurse in the state of Indiana.

Knowledge, Skills, and Abilities:

• Must have experience in case management or care management (Certified Case Manager preferred)
• Must have experience with Medicare/Medicaid
• Experience with multiple EHR/EMR systems
• Ability to work collegially with staff members from multiple offices
• Ability to manage multiple patients simultaneously
• Ability to build and maintain relationships with patients, families and client providers
• A background in geriatric care, family medicine and/or long-term care (skilled nursing, home health, hospice, public health, assisted living) highly preferred.
• A background and ability to work with populations with special needs
• Competence and experience with electronic charting
• Ability to multitask
• Excellent written and verbal communication skills.
• Self-directed with the ability to work independently and in groups
• Exceptional time management skills, with a high level of individual initiative
• Detail oriented with strong organizational, planning, and problem solving skills
• Can be depended upon to effectively plan and organize multiple assignments to ensure workload's completion, yet flexible enough to handle changing schedules

Special Demands/Requirements:

Occasional, local travel may be required for off-site meetings.

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Job tags

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Salary