Summary of Position

* Provides in person and or telephonic Case Management Services to identified high risk PHSO (Population Health Service

Organization) patients within the community including but not limited to Physician Practices and Neighborhood Care Centers.

* Consults with patients on their medications and durable medical equipment, reviewing patient care plans, addressing home

care needs, and connecting patients to community resources.

* Collaborates with primary care physicians and other providers to ensure there are no gaps in care; the goal to improve health

care outcomes and appropriate and timely utilization of services across the continuum of care.

* Collaborates with patients, providers, and caregivers to ensure positive care outcomes during care transitions.

Principal Accountabilities

* Provides patient education to assist with self-management, educate on disease processes, and encourage healthy

lifestyle changes. Includes patient and family as appropriate. Engages actively with the primary care provider (PCP)

/designee.

* Engages with the patient in support of their treatment team to identify and establish attainable goals that positively

impact clinical, financial, and quality of life outcomes.

* Assesses the needs of patients and aligns them with the appropriate member of the care team (wellness team,

registered dietitian, social worker) and develops a patient-centric care plan.

* Monitors, documents, and tracks care team performance to ensure patients are engaged in a timely fashion and

that performance metrics (Admits, ER utilization etc.) meet or exceed established thresholds.

* Provides ongoing monitoring, evaluation, support, and guidance to the coordination of the patient's health care.

* Ensures that discharged patients receive the necessary services and resources, including medication reconciliation

and coordinating services such as home health and DME, as needed.

* Works collaboratively with medical office team members with the goal of maintaining team performance and high

morale.

Education, Training, Licenses, Certifications

* Current, unencumbered New York State Registered Nurse license (R)

* CCM (Case Management) certification (P)

* Bachelor's degree (P)

Relevant Work Experience, Knowledge, Skills, and Abilities

* Minimum 4 - 6 years' RN clinical experience. (R)

* Excellent verbal and written communication skills, including phone etiquette. (R)

* Strong working knowledge of Microsoft Office applications including proficiency in MS Word and Excel (R)

* Proficiency in the use of EMR (Electronic Medical Record) systems

* Ability to effectively manage a team of highly complex patients (R)

* Ability to support an integrated care model tapping into appropriate resources both internally and external to the

organization. (R)

Additional Information Requisition ID: 1000001958Hiring Range: $75,000-$95,000 Minimum Salary: 31200.00Maximum Salary: 31200.00Salary Unit: Yearly