Community Care RN, Full Time

Position Summary Position Summary Directly responsible for providing high quality clinical care management services to patients aligned with the health system's valuebased care programs in collaboration with clinical and administrative stakeholders. Serves as part of a multi-disciplinary team to support patients by assessing individual risk factors, developing comprehensive care management plans, encouraging preventive care services, and following targeted evidence-based clinical protocols to optimize clinical utilization management and care outcomes for patients and their families. Responsibilities Essential Functions Understands broad principles related to care management, healthcare operations, value-based care, insurance and payor relationships, organizational and departmental strategies, patient engagement, physician relations, and all other relevant clinical care delivery requirements. Coaches patients through their healthcare journeys by providing education about their condition, healthcare delivery, and clinical programs to decrease the risk of unnecessary emergency room visits or hospital admissions and encouraging use of the right resources at the right time. Identifies and removes barriers to appropriate utilization of resources for patients leverages health system solutions, including effective communication with management, to remove barriers as they arise. Contributes to problem solving within the team through communication, collaboration, data collection, critical thinking, evaluation of options and potential solutions to further the patient progress towards care plan goals. Meets established service level objectives for productivity, performance, and quality to support the achievement of system objectives and strategic imperatives. Takes initiative to develop knowledge, skills, and abilities to perform at a high level, including staying abreast of related care management news, documentation, literature, and continuing education. Communicates with third party payors and value-based care partner care teams, as appropriate and necessary, to ensure patients receive the most coordinated care possible in collaboration with all external stakeholders. Ensures compliance with all necessary risk management programs, corporate quality initiatives, and other corporate objectives. Leverages care management tools to effectively identify patients for various clinical protocols, including extensive review of frequent or unnecessary utilization patterns, unmanaged chronic diseases, and nonadherence to treatment regimens. Assesses unique patient needs to design individualized plans of care including chronic disease/complex condition management strategies, targeted health literacy and education materials, social determinants of health resources, and caregiver support plans. Coordinates with partner organizations and services to mitigate barriers to care, such as prescription drug programs, health and wellness programs, housing support services, durable medical equipment vendors, and public and private agencies, among others. Partners with various healthcare entities and physician practices to foster integrated relationships with patients, families, and caregivers, and to facilitate a streamlined patient experience across the continuum of care. Advocates for patients to optimize their own health and wellbeing using evidence-based standards of care, encouraging effective self-management strategies, and via referrals to in-person and virtual resources designed to track and improve outcomes. Supports quality initiatives collaboratively developed with payor partners through care gap closure campaign outreaches designed to engage patients and caregivers, increase treatment adherence, and better health outcomes for our covered populations. Monitors care plan progress with an emphasis on patients at the highest risk for clinical complications and/or avoidable events, and routinely evaluates continuous improvement opportunities to modify treatment plans, as needed. Maintains a high level of proficiency with organizational informational systems, including ELLiE and the associated Healthy Planet modules, to ensure care coordination support for our covered populations is efficient, timely, and effective. Participates in initiatives to support the health system's Accountable Care Organizations (ACOs), Bundled Payment programs, and clinical/physician practice operations, including use of effective cost and utilization management strategies. Provides concise and relevant information, data findings, and recommendations to health system leadership to assist in the development and execution of value-based strategies and network development, as necessary. Performs other duties as assigned to support the health system's overall population health and value-based care team objectives. Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state, and local standards. Other Related Functions Works comfortably in teams as a participant and facilitator, including temporary teams for project-based initiatives. Possesses the ability to prioritize and work independently in addition to being an integral part of the care team. Documents work efforts in an organized and accessible fashion while respecting confidentiality/privacy standards. Qualifications Education/Training Associate of Science in Nursing (ASN) or Associate of Social Work (ASW) or other similar Associates degree program required. Bachelor of Science in Nursing (BSN) or Bachelor of Science in Social Work (BSW) or other similar bachelor's degree program preferred. Licensure/Certification Maintains current Florida Registered Nursing (RN) license. Experience Two (2) or more years of direct patient care experience in a hospital, post-acute care, physician office setting, value-based care/population health department, and/or other similar care coordination settings.

Education/Training Associate of Science in Nursing (ASN) or Associate of Social Work (ASW) or other similar Associates degree program required. Bachelor of Science in Nursing (BSN) or Bachelor of Science in Social Work (BSW) or other similar bachelor's degree program preferred. Licensure/Certification Maintains current Florida Registered Nursing (RN) license. Experience Two (2) or more years of direct patient care experience in a hospital, post-acute care, physician office setting, value-based care/population health department, and/or other similar care coordination settings.

Essential Functions Understands broad principles related to care management, healthcare operations, value-based care, insurance and payor relationships, organizational and departmental strategies, patient engagement, physician relations, and all other relevant clinical care delivery requirements. Coaches patients through their healthcare journeys by providing education about their condition, healthcare delivery, and clinical programs to decrease the risk of unnecessary emergency room visits or hospital admissions and encouraging use of the right resources at the right time. Identifies and removes barriers to appropriate utilization of resources for patients leverages health system solutions, including effective communication with management, to remove barriers as they arise. Contributes to problem solving within the team through communication, collaboration, data collection, critical thinking, evaluation of options and potential solutions to further the patient progress towards care plan goals. Meets established service level objectives for productivity, performance, and quality to support the achievement of system objectives and strategic imperatives. Takes initiative to develop knowledge, skills, and abilities to perform at a high level, including staying abreast of related care management news, documentation, literature, and continuing education. Communicates with third party payors and value-based care partner care teams, as appropriate and necessary, to ensure patients receive the most coordinated care possible in collaboration with all external stakeholders. Ensures compliance with all necessary risk management programs, corporate quality initiatives, and other corporate objectives. Leverages care management tools to effectively identify patients for various clinical protocols, including extensive review of frequent or unnecessary utilization patterns, unmanaged chronic diseases, and nonadherence to treatment regimens. Assesses unique patient needs to design individualized plans of care including chronic disease/complex condition management strategies, targeted health literacy and education materials, social determinants of health resources, and caregiver support plans. Coordinates with partner organizations and services to mitigate barriers to care, such as prescription drug programs, health and wellness programs, housing support services, durable medical equipment vendors, and public and private agencies, among others. Partners with various healthcare entities and physician practices to foster integrated relationships with patients, families, and caregivers, and to facilitate a streamlined patient experience across the continuum of care. Advocates for patients to optimize their own health and wellbeing using evidence-based standards of care, encouraging effective self-management strategies, and via referrals to in-person and virtual resources designed to track and improve outcomes. Supports quality initiatives collaboratively developed with payor partners through care gap closure campaign outreaches designed to engage patients and caregivers, increase treatment adherence, and better health outcomes for our covered populations. Monitors care plan progress with an emphasis on patients at the highest risk for clinical complications and/or avoidable events, and routinely evaluates continuous improvement opportunities to modify treatment plans, as needed. Maintains a high level of proficiency with organizational informational systems, including ELLiE and the associated Healthy Planet modules, to ensure care coordination support for our covered populations is efficient, timely, and effective. Participates in initiatives to support the health system's Accountable Care Organizations (ACOs), Bundled Payment programs, and clinical/physician practice operations, including use of effective cost and utilization management strategies. Provides concise and relevant information, data findings, and recommendations to health system leadership to assist in the development and execution of value-based strategies and network development, as necessary. Performs other duties as assigned to support the health system's overall population health and value-based care team objectives. Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state, and local standards. Other Related Functions Works comfortably in teams as a participant and facilitator, including temporary teams for project-based initiatives. Possesses the ability to prioritize and work independently in addition to being an integral part of the care team. Documents work efforts in an organized and accessible fashion while respecting confidentiality/privacy standards.