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Integrated Care Management Nurse
3 months ago
Integrated Care Management Nurse
Full Time position
For all CHP region sites (Bozeman, Belgrade & Livingston)
POSITION SUMMARY:
The coordinator is a One Health employee with a specialized skill set or education and makes a significant contribution to the organization’s potential to achieve its mission. Under the direction of assigned One Health leadership, coordinators work with a high sense of initiative and responsibility to provide guidance or work product in a specialty area.
Provides professional level nursing service focusing on assessment and implementation of the patient’s clinical care plan in order to improve health outcomes. Functions as a member of the primary health care team under the general supervision of CHP Regional Clinic Director.
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES:
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.
Coordinator Duties and Responsibilities
- Utilizing advanced specialty knowledge and/or skills, provides coordination of organizational projects, programs, grants etc.
- Functions in a self-directed and professional manner with both external and internal stakeholders.
- Facilitates maintenance of and development of initiatives within service and business line functions.
- Collaborates and communicates within teams and across organizational and business lines to involve appropriate stakeholders in development and maintenance of specialty area initiatives.
Position Specific Duties and Responsibilities
- Provides medical care management services in collaboration with the provider care teams, resource coordinators, clinical pharmacists, and behavioral health consultants including offering support for the medical respite program through Human Resource Development Council and Bozeman Health.
- Creates individualized care plans for patients receiving care management services and shares these with the patients.
- Ensures patients proactively identified through medical home workflows receive care management services and documentation supports compliance requirements.
- Educates and counsels patients using easy to understand (health literate) language.
- Makes referrals to community, health and social services and provide liaison with these services as indicated. Advocates for patients while maintaining relationships with community healthcare providers.
- Perform laboratory tests, counsel and educate patients prior to and following physical exams and testing.
- Identify patients’ problems or needs, determine which ones a clinician must evaluate and refer accordingly.
- Maintains acceptable methods of charting and record keeping providing for consistent, organized patient care per clinic policies and procedures.
- In coordination with clinical care teams, promote the smooth functioning of care delivery and addition of new lines of care management services.
- Participate in Value Based Care delivery as it relates to care management and care transitions.
- Trains and supports clinic staff in offering care management, including supporting provider team panel management.
- Exemplifies a patient-centered care approach to each patient along each stage of the patient journey, while working as a key patient centered team member by communicating individual patient care needs to support the needs of patients served.
- Adheres to all One Health Policies and Procedures.
- Participates in performance optimization and risk management activities as required.
- Cooperates and abides by all elements of One Health’s Compliance Program.
- Provides exceptional customer service and models the mission of One Health when interacting with internal and external stakeholders promoting a positive image for the health center.
- Performs other duties as assigned or required with prior notification.
MINIMUM JOB QUALIFICATIONS:
Education/Certificates/Licenses:
Required
- Nursing degree from an accredited nursing program
- Current license in state of practice
- Valid driver’s license
- BLS certification upon hire
Preferred
- Registered Nurse
Experience:
Required
- One (1) year of experience in community health or related field such as Family Medicine, Primary Care, or hospital Case Management
Preferred
- Two years of community health and/or physician’s office experience
- Two years of care management experience
