Remote position

BI-LINGUAL SPANISH A PLUS

Uses the nursing process with at-risk patients to assess, plan, implement and evaluate clinical strategies leading to quality results, optimal cost/utilization and patient experience. Works across the care continuum to support patients in addressing the following dimensions of care: clinical management, education/knowledge, psychosocial needs, self-management, advocacy, and continuity of care. Establishes an ongoing, therapeutic relationship with the patient/family to improve access, reduce burden of disease, manage care transitions and increase use of appropriate access points of care.

Major Responsibilities:

Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team.Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements.Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care.Coordinates referrals to other internal AAH departments and/or external community resources as necessary.

Licensure, Registration, and/or Certification Required:

Registered Nurse license issued by the state in which the team member practices.

Education Required:

Bachelor's Degree in Nursing or related field.

Experience Required:

Typically requires 5 years of experience in clinical nursing or 1-2 years of care management experience.

Knowledge, Skills & Abilities Required:

Care Management/Transition Certification within 2 years of employment for full time employment; n/a with advanced degree/active enrollment in masters program.Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.Ability to demonstrate excellent oral, written and interpersonal skills.Ability to demonstrate critical thinking, problem solving and excellent organizational skills.Ability to work productively and effectively in a complex environment that includes multiple changing priorities.Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.Proficient computer/Microsoft-suite skills and previous Epic EMR experience.Ability to handle multiple responsibilities.BI-LINGUAL SPANISH A PLUS!

Physical Requirements and Working Conditions:

Position may require travel between clinic sites so there may be exposure to road and weather conditions.Manual dexterity required for operation computer and calculator.Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.Exposed to normal office environment; including usual hazards related to operating electrical equipment.Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.