POSITION MISSION – FUNCTION The Value Based Care Nurse (VBCN) will facilitate the coordination of patient care across the continuum. The VBCN will partner with Primary Care Physicians and their staff to aid them in providing high quality, well-coordinated patient care.

　　This will be accomplished by developing interactive relationships with the primary care provider and their support staff in order to keep multi-directional communication at the forefront of all patient encounters.

　　The VBCN will work alongside the PCPs, patients, SDOH, Respiratory and Pharmacy teams to ensure that smooth, cost effective transitions of care are achieved, readmissions are minimized and wellness goals are attained. RESPONSIBILITIES : [Key position functions which support the critical success factors]

　　 Telephonic communication with patients to gather clinical information, encourage routine and urgent PCP appointments are made, and provide education around disease self-care.

　　 Reduce readmissions through direct patient outreach and communication with the PCP

　　 May make periodic visits to PCP offices

　　 Meet with PCP’s and their staff as needed, to discuss high risk patient status, discharge plans, hospitalization avoidance strategies and ensure end of life preferences are identified

　　 Review recent admission trends and history with PCP and staff

　　 Communicate directly with patients experiencing transitions in care for a prescribed length of time to determine if post discharge needs are met, follow-up appointments are made and kept, and complete the TOC assessment in Arcadia  Act as a Health Coach, providing patient education with a goal of improving their overall health while improving the ACO quality measures

　　 Collaborate with Local Network Operations Team on a scheduled and as needed basis

　　 Document all interactions and workflow management in a concise and accurate manner in appropriate tool

　　 Identify/ receive notification of DCE patient admissions and discharges in the acute care setting or SNF as available via ADT feeds

　　 Develop and maintain collaborative relationships with key personnel in high volume post-acute care facilities to coordinate with the facility discharge planner to ensure an appropriate transition of care plan is in place

　　 Communicate directly with patients to determine post discharge preferences, discharge needs and work with the hospital or post-acute care management staff to ensure appropriate plans are in place

　　 Act as a resource for the PCP and communicate admissions, discharges and discharge plans for high risk patients to the PCP and their staff

　　REQUIREMENTS: This is considered a work from home position. Occasional travel to PCP offices may be required.

　　Experience/ Education:

　　 Current unrestricted state RN license  Baccalaureate degree preferred

　　 Three or more years of clinical experience in an acute care, post-acute care or community setting

　　 Minimum of two years of experience in Case Management, Utilization Review, or Population Heath

　　 Experience with physician’s office practices preferred

　　Knowledge: Must possess or attain knowledge of:  Medicare regulations and MSSP regulations

　　 HIPAA regulations

　　 Knowledge of care management-utilization management, discharge planning, population health

　　 Bilingual (Spanish) is preferred

　　GENERAL SKILLS:

　　 Excellent communication and presentation skills required

　　 Proficient in computer skills including: Microsoft office suite (Outlook, Excel, Word) quickly learns new computer software and ability to utilize internet based programs

　　If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

　　For this position, we anticipate offering an annual salary of 68,700 - 114,500 USD / yearly, depending on relevant factors, including experience and geographic location.

　　This role is also anticipated to be eligible to participate in an annual bonus plan.

　　We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

　　About Cigna Healthcare

　　Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

　　Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

　　If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.

　　The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.