Purpose:

　　Physician office based position. Supports the practice physicians in coordination of care, developing care plans, reducing barriers to care and provide follow up for highly complex patients in the practice. This includes coordination of practice, community and health insurance resources; and working closely with the patient, family and care givers, and all involved providers ,including the Expanded Care Team support staff for the patients in the practice (s).

　　Responsibilities:

　　Works very closely with and maintains open communications with the Primary Care Physician of the extensive care program for direction and collaboration related to patient needs and assessment.

　　Once patient is ready to leave the program, facilitates transition back to the Primary Care Doctor of the patients.

　　Assess patient's appropriateness for enrollment into the Chronic Care Management program in terms of meeting criteria, approval by PCP, and patient and families willingness to participate.

　　Follows up with patient and/or care givers regularly to assess patient's medical status or compliance to plan or or to offer assistance as needed.

　　Actively participates in planned team meetings to monitor patient's status, evaluate the effectiveness of the individualized plan of care, and identify new needs and strategize for next steps.

　　Documents all assessments, interventions and plans of care completely and accurately into the electronic health record.

　　Maintains availability to patient and /or care giver as needed by phone or visit. Rotates call by phone according to systems developed in the practice for Chronic Care Management program.

　　Meets face to face with patients and family members initially and as needed to build a relationship, assess the patient's medical, behavioral health and social needs, identify barriers

　　In collaboration with the team, develops and coordinates an individualized plan of care with the patient, patient's family, health insurance plan, providers and community agencies as applicable. Involves additional providers as needed to support the individualized plan of care based on identified needs of the patient and family and/or care giver. Plan designed to promote health, close gaps in care, decrease unplanned care.

　　Graduate of approved school of nursing.

　　Two (2) years of nursing experience in an outpatient setting required

　　BSN or related Bachelor's degree preferred.

　　Experience in a physician practice and/or home health care highly desired.

　　Previous case management experience preferred.

　　Ability to interact with physicians and other health care professionals in a professional manner required. Must have an understanding of health care disparity issues and have the ability to interact with members from diverse backgrounds in a culturally appropriate manner. Excellent verbal and written communication and interpersonal skills required. Ability to use independent judgment and compassion when carrying out tasks.

　　Must be flexible with work schedule and may have to travel between offices as needed to see patients and or huddle with office staff. Must have flexibility to work within the hours established by the practice and to adapt to a changing environment while still functioning effectively as part of a multidisciplinary team. Licensure, Certifications, and Clearances:

　　Registered Nurse (RN)

　　UPMC is an Equal Opportunity Employer/Disability/Veteran