Location
Jacksonville, NC | United States
Job description
Essential Functions
- Responsible for ensuring the delivery of effective and appropriate care management services to patients who have high rates of utilization with priority focus on the Advanced Medical Home (AMH) Program for NC Medicaid and Chronic Care
- Management/Transitional Care Management (CCM/TCM) services allowable under Medicare.
- Proficiently and systematically use claims data to outreach patients to engage with care management
- Collaborate with primary health care team on patient focused care
- Perform Post Hospitalization and Emergency room follow up care, education, and intervention to decrease risk of readmission
- Ensures that discharge instructions, follow up appointments and discharge medications are reviewed with patient and coordinates care with primary health care team
- Coordinates transitional and pre-discharge care with the facility care team
- Utilizes motivational interviewing techniques to assess a patient’s condition knowledge and partner to establish patient focused care plans, to enhance long term health and wellness
- Documents assessments and progress clearly and concisely related to all care management assessments, goals, and outcome in accordance with organizational policies and procedures.
- Apply evidenced based Quality Improvement process per National Standards of Care.
- Provide effective Care Management services based on case management standards of practice to enrolled populations.
- Complete comprehensive assessments utilizing a wholistic approach, inclusive of medical, psychosocial, behavioral, spiritual and cultural needs to enrolled population, throughout the continuum of care.
- Develop, review, and evaluate the patient care plan in partnership with the patient, caregiver/family members, providers, and Care Management team members, as applicable.
- Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care.
- Implement Care Management interventions per the patient’s care plan. Delegate tasks to care team members as appropriate.
- Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management.
- Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families.
- Create referrals per protocol to members of the patient interdisciplinary and/or clinical team appropriately, accurately, and timely according to established workflows.
- Serve as a liaison among the patient/family, community services, primary care providers, specialists, and other care team members to coordinate services without duplication.
- Adhere to AMM organizational, privacy and security policies alongside HIPAA regulations to ensure that patient and network data are properly safeguarded.
- Attend departmental, case reviews and corporate meetings, local and regional trainings, or other events as required
- Willingly performs other duties as assigned.
- Strong collaboration with interdisciplinary team to achieve patient centered care
Minimum Qualifications: - Minimum of Associates Degree from an accredited School of Nursing with three years of clinical nursing experience.
- Current, unrestricted North Carolina RN license
- Critical care or Care/Case management experience strongly preferred
- Certified Case Manager (CCM) strongly preferred
Additional skills required: - Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e-mail communication.
- Consistently reliable, self-directed, prioritizing tasks effectively, strong time management; efficient and organized.
- Must be able to interact with individuals of all cultures and levels of authority.
- Requires the ability to maintain confidentiality.
Benefits: - 401(k)
- Health, Dental and Vision insurance
- Employee assistance program
- AFLAC
- Paid time off
Job tags
Salary
