JOB DESCRIPTION

Collaborates with providers and clinic staff to identify and prioritize patients appropriate for care coordination services, utilizing care coordination criteria.
Performs initial, holistic assessments for care coordination population. Prioritize patients according to intensity, need, and required follow-up. When working with an LPN Care Coordinator, delegate periodic care coordination as appropriate. Provide education regarding disease management based on current best practice standards. Triage patients escalated for re-evaluation by the LPN Care Coordinator.
Knowledge of current federal, state, and local programs as well as their eligibility requirements and application process in order to pro-actively connect patients with appropriate resources.
Develops care coordination plan and goals mutually agreed upon by patient/family. Utilize motivational interviewing techniques and assist patient in meeting action-oriented goals and objectives.
Evaluates effectiveness of plan in meeting established care goals, revise as needed. When working with an LPN Care Coordinator, collaborate for patients who may need care plan and goal revision.
Interacts professionally with patient/family to achieve maximum levels of wellness and independence.
Performs initial calls for patients recently discharged from the hospital who are considered high risk for readmission. When working with an LPN Care Coordinator delegate weekly follow up calls until the patient has been discharged for 30 days. Ensure that the patient has attended follow up appointments as scheduled and is adherent to medications. Provide patient with education regarding hospital diagnosis. Identify patients who have had a change in condition and escalate care to provider or EMS services as appropriate.
Performs face-to-face patient visits in order to update medical/surgical/family history, review current medications and allergies, assess social determinants of health, provide appropriate health screenings, assess for functionality, and review medical record for gaps in care. Conduct shared decision-making conversations with patient in order to close care gaps. Report findings to provider.
Assists patients in developing advanced care planning.
Serve as liaison to providers, patients and families for coordination of services.
Maintains EMR databases on care managed population. Maintain accurate and timely documentation and billing. Triage patients escalated by LPN Care Coordinator for review/updating of care plan. Revise care plan at least once per year according to standards set by CMS.
Review utilization and quality reports routinely, scan for gaps in care and identify patients needing the additional support of care management.
Participates in regular team meetings. Participates in departmental and organizational committees as applicable. Participates in the orientation of new personnel. Precepts and acts as a mentor to peers. Promotes collaborative teamwork.
Meet with Manager of Population Health Outpatient Care Coordinator and if applicable the LPN Care Coordinator team member on a regular basis to provide patient updates, identify issues, and develop strategies for resolution.
Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing. Ensures documentation meets current standards and policies.
Attends conferences, workshops, and complete continuing education as assigned.

EDUCATION

Bachelor’s degree in Nursing (BSN) is required.

EXPERIENCE

3 years relevant nursing experience including a minimum of 2 years’ nursing case management experience, preferably with older patients, is preferred.
Navigation experience in outpatient setting preferred.

QUALIFICATIONS

Experience in one of the following required
Previous Navigation Experience in outpatient setting
Case Management
Home Health/Public Health
Case Management Certification required within 2 years of hire.
Knowledgeable in stages of human growth and development for adult and geriatric populations.
Skills in interpersonal relationships, clinical assessment, group process and high levels of verbal and written communication.
Ability to interact with other professionals as part of a multidisciplinary team, displaying good judgment and decision-making skills.
Skills in interpersonal relationships, clinical assessment, group process.
Self-directed with the proven ability to work independently essential.
Knowledge of funding, resources, clinical standards and outcomes for population.

Please refer the Job description for details