Population Healthcare Management RN Ryan White

Position Summary: The Population Health Care Management RN-Ryan White complements the practitioner-patient relationship through support of the established plan of care, using cost-effective, recommended practice guidelines in support of the HIV continuum. The goal is to address any acute needs as well as to prevent or delay severe stages of disease progression and enhance the client's quality of life. In doing so, this position helps to reduce complications and morbidities to improve health and reduce the costs of the client's healthcare services. Job functions are performed in accordance with Community Care Plan Health Services (CCP) policies and procedures, Memorial Healthcare System standards of conduct, and Patient Centered Medical Home (PCMH) standards. Essential Duties and Responsibilities: * This position coordinates, educates, and provides expertise to clients living with HIV/AIDS across the continuum of care from complex medical to chronic conditions as well as promote compliance with preventative care measures. * The position coordinates healthcare interventions designed to facilitate care at the lowest level that can safely be achieved focusing on closing immediate goals and empowering clients to self-manage chronic conditions and emphasize control of the disease. * Practices onsite, at Memorial Healthcare System's Division of Infectious Disease, works as part of a multi-disciplinary team of professionals, to coordinate efforts to identify clients with highest level of morbidity, risk, lack of adherence, barriers to access or retention in care, and implement a plan to address these needs. * Conducts or participates in Multidisciplinary Case staffings and team huddles to review strategies, identify clients or providers with immediate needs and develop a plan of action to provide quality care. * Analyze clinical information to identify clients and to determine eligibility and appropriateness for enrollment in the Ryan White Disease Case Management program. * Review daily provider schedule for any clients in their panel scheduled to see the physician and; attempt face-to-face visits and education as needed. * Provide outreach to any client identified as having a chronic condition(s), not well managed or with multiple gaps in care and in need of preventive services. * For all clients enrolled, conduct a thorough needs assessment, including a risk stratification to determine health, psychological, educational, and social needs, and the level of care requirements. * In collaboration with the physician and client, develop an individualized care plan. * Establish Specific, Measurable, Achievable, Realistic and Time bound goals that includes the client's strengths and resources to address identified needs, improve client's quality of life, and and promote positive health outcomes. * Collaborate with healthcare team in assessing the progress, toward individual health care goals, to optimize patient adherence to medical plan of care, including medication adherence, evidence-based care, and specific screenings for recommended preventive care. Complete electronic referrals, medication refills and pend to primary care provider as appropriate * Assess barriers when client has not met treatments goals, is not following treatment plan of care, or has not kept important appointments. * Update the client care -plan as changes in status occur and at least quarterly; communicate with the multidisciplinary team as indicated. * Provide client education on disease process and healthy lifestyle changes; reminders, and/or telephone calls to improve self-management of specific conditions that are consistent with clinical practice guidelines. * Support the practitioner-patient relationship and plan of care with an emphasis for the prevention of disease exacerbation and complications. * Educate clients regarding shared decision-making tools to ensure the client is informed of all care options and potential harms and benefits. * Maintain requirements of documentation as reflected in the Ryan White Service Delivery Model to meet compliance with quality standards and acknowledges patient's rights on confidentiality issues, maintaining patient confidentiality at all times, and following all HIPAA guidelines and regulations. This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management. Skills and Abilities: * Ability to self-motivate. * Ability to communicate effectively. * Exceptional skills of independence, organizational, communication, problem-solving, professional interaction, and human relation skills, as well as analytical skills and problem-solving ability. * Proficient with processes to build teams and participate in cross-functional teams. * Ability to follow a project or assignment through to successful completion. * Experience with motivational interviewing techniques and adult learning styles. * Decisive judgment and ability to work with minimal supervision. * Excellent oral and written communication skills, with problem-solving abilities. * Exceptional interpersonal communication skills are required. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 15 pounds. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion. Qualifications * Registered nurse licensure in the State of Florida. * Certified case manager or certified diabetes educator preferred. * Minimum of five years of clinical experience or two years of case or disease management experience in a Ryan White service provider, health system, health maintenance organization or disease management organization with experience in HIV/AIDs care . * Knowledge of Microsoft Office and internet software.