**It's more than a career, it's a calling** WI-SSM Health Erdman **Worker Type:** Regular **Job Highlights:** This position includes telephonic outreach (occasional video visit also) for patients with chronic conditions to assess and educate, work on goals to improve outcomes, assist with care coordination and closing care gaps. Also outreach after hospital discharges or ED visits etc. Work with providers, clinic staff and ancillary staff regarding care plans, coordination and resources for needs identified. -Hybrid opportunity must be able to work onsite (1 Erdman Place, Madison, WI) three days a week while two days a week will be remote. -While training, staff must be able to work 100% in office. **MUST LIVE IN WI -Schedule is Monday through Friday 8 to 430pm. No nights, weekends or holidays. **Job Summary:** Utilizes skilled intervention, clinical best practice knowledge and collaboration with the patient, physician and multidisciplinary treatment team to pace care, achieve quality outcomes and negotiate appropriate reimbursement. Ensures the timely and seamless clinical transition of patients through medically appropriate levels of care. **Job Responsibilities and Requirements:** PRIMARY RESPONSIBILITIES + Reviews all patients identified for review to determine the medical necessity and appropriateness of enrollment in the care management program. + Assesses all assigned patients and integrates family information from social work to collaboratively determine potential, actual and the next level of care needed. + Holds, interprets, and integrates the patient’s story into the overall multidisciplinary plan of care. + Coordinates and facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes. + Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting. + Actively participates in clinical performance improvement activities as assigned. + Builds a network of positive working relationships that advocate for the patient. + Documents clinical activity in the medical record and supports and coaches accurate clinical documentation by physicians and others. + Pursues continuing education in area of expertise/leadership. + Works in a constant state of alertness and safe manner. + Performs other duties as assigned. EDUCATION + Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE + Two years' registered nurse experience PHYSICAL REQUIREMENTS + Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. + Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. + Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. + Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. + Frequent keyboard use/data entry. + Occasional bending, stooping, kneeling, squatting, twisting and gripping. + Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. + Rare climbing. **Work Shift:** Day Shift (United States of America) **Job Type:** Employee **Department:** 8149000069 Project Vibrance **Scheduled Weekly Hours:** 40 _SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity,_ _pregnancy, veteran status_ **_,_** _or any other characteristic protected by applicable law._ Click here to learn more. (https://www.ssmhealth.com/privacy-notices-terms-of-use/non-discrimination?\_ga=2.205881493.704955970.1667719643-240470506.1667719643)