Job Summary
Oversees care management and coordination activities for patients of a primary care practice.
Job Responsibilities
- Works with clinical teams as a resource on care management of patients including pre-visit planning workflow to ensure care completion prior to visit and after-visit summary review with patients when appropriate.
- Involves the patients in activities to improve their health (patient engagement) and educates patients about self management tasks they can undertake to gain greater control of their health status.
- Works with physician leadership to develop protocols and point of care reminders using nationally recognized EBC measures and outcomes. Defines quality measures and outcomes reporting processes. Serves as a resource to clinical staff and providers to establish quality goals using reports.
- Works with IT resources to facilitate registry reporting at the site and documentation of EBC in searchable fields.
- Works with IT resources to coordinate efficient consult request communication and consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all, and reporting of progress towards goals.
- Manages assigned panel of chronic care patients (high acuity).
- Develops relationship with patients as an integral member of team by providing follow-up contact with patient as indicated to ensure compliance with recommendations--medications, lab/x-ray, specialist visits, PCP visits, dietitians, CDE, etc. Manages many aspects of the patient's care including referral to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.
- Provides telephone advice per protocol and handles urgent and emergent calls.
- Works with patient and patient's care team to coordinate change readiness, needs assessment and develops an individualized treatment care plan.
- Assists patient in setting SMART goals for self-management, teaching them how to do self-management tasks, and report abnormal findings to their physician team.
- Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals.
- Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
- Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
- Collaborates with payer Care Managers for additional services when appropriate.
- Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
- Works with consulting physicians, hospitals, emergency department, and other frequently used healthcare sources to clarify roles, develop effective, efficient, and timely communication between primary care physician (PCP) and these entities.
- Facilitates physician leadership to develop written agreements with consulting physicians, key facilities, and community resources to define the roles and method of communication.
- Coordinates consultations and/or referrals, hospital/emergency department, community resources follow-up and tracking process for the practice; works to have clerical component done by appropriate clerical staff whenever possible.
- Develops workflows and protocols within the individualized treatment care plan that ensures emergency department, hospital, and community resource follow-up.
Qualifications
- Associate's degree or higher or Diploma in Nursing required upon hire
- No experience required
- RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire AND
- BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position
Skills and Attributes
- Requires critical thinking skills and decisive judgment.
- Works under minimal supervision.
- Must be able to work in a stressful environment and take appropriate action.
Physical Demands
- Standing: Occasionally
- Walking: Occasionally
- Sitting: Frequently
- Lifting 0-25 lbs: Rarely
- Lifting 25-75 lbs: Never
- Lifting over 75 lbs: Never
- Carrying 0-25 lbs: Rarely
- Carrying 25-75 lbs: Never
- Carrying over 75 lbs: Never
- Pushing/Pulling 0-25 lbs: Rarely
- Pushing/Pulling 25-75 lbs: Never
- Pushing/Pulling over 75 lbs: Never
- Climbing: Rarely
- Bending/Stooping: Rarely
- Kneeling: Rarely
- Crouching/Crawling: Rarely
- Reaching: Occasionally
- Talking: Frequently
- Hearing: Occasionally
- Repetitive Foot/Leg Movements: Never
- Repetitive Hand/Arm Movements: Frequently
- Keyboard Data Entry: Frequently
- Running: Never
- Vision: Depth Perception: Frequently
- Vision: Distinguish Color: Frequently
- Vision: Seeing Far: Frequently
- Vision: Seeing Near: Frequently
Owensboro Health Core Commitments
INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.
RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.
TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.
INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.
SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.
EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.