Population Healthcare Management RN Clinic

Position Summary: This position coordinates, educates, and provides expertise to members 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 members to self-manage chronic conditions and emphasize control of the disease. The Concierge Care Coordination Nurse at the clinic complements the practitioner-patient relationship through support of the established plan of care, using cost-effective, recommended practice guidelines. The goal is to address any acute needs as well as to prevent or delay severe stages of disease progression and enhance the member's quality of life. In doing so, this position helps to reduce complications and morbidities in an effort to improve health and reduce the costs of the member's healthcare services. Job functions are performed in accordance with requirements of the Medicaid contract, Community Care Plan (CCP) Health Services policies and procedures, and Patient Centered Medical Home (PCMH) standards. Essential Duties and Responsibilities: * This position coordinates, educates, and provides expertise to members 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 members to self-manage chronic conditions and emphasize control of the disease. * Assigned to one or more physician practices, leads a multi-disciplinary team of professionals, to coordinate efforts to identify clients with highest level of morbidity, risk, utilization, cost and gaps in care and implement ways to collaborate with providers to improve outcomes and quality of care. * Conduct or participate in 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 members and to determine eligibility and appropriateness for enrollment in the Concierge Care Coordination Program. * Review daily census for any enrollee in their panel admitted to the hospital; assess need for and coordinate discharge planning as needed. * Assess hospitalized enrollees for the need for ongoing care coordination, disease management or open gaps in care, working with hospital and providers to meet enrollee needs. * Conduct outreach and follow-up on any enrollee with a pattern of emergency room visits to assess for contributing factors and develop actions to reduce avoidable emergency room and potentially avoidable hospital admissions. * Provide outreach to any enrollee identified as having a chronic condition(s), not well managed or with multiple gaps in care and in need of preventive services. * For all enrollees identified for care management, conduct a thorough needs assessment, including a risk stratification is completed to determine health, psychological, educational and social needs, and the level of care requirements. * In collaboration with the physician and enrollee, develop an individualized care plan. * Establish Specific, Measurable, Achievable, Realistic and Time bound goals that address identified needs, improve member quality of life, and promote evaluation of the cost and quality outcomes of the care provided. * 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 member has not met treatments goals, is not following treatment plan of care, or has not kept important appointments. * Update the member care -plan as changes in status occur and at least annually; communicate with the multidisciplinary team as indicated. * Provide member education on disease process and healthy lifestyle changes; via phone call, texting messages and or face to face to improve self-management of specific conditions that are consistent with clinical practice guidelines. * In conjunction with Concierge Care Coordination Health Social Worker, may conduct in-home assessments, on an as needed basis, to assess the member's home environment to evaluate for safety, appropriateness of setting and to ensure member has all needed supplies and medications. * Conduct multidisciplinary team conferences as needed for any client with significant clinical, social or behavioral health concerns, who has been unable to eliminate barriers to care and who would benefit from a more collaborative approach to address needs. * Support the practitioner-patient relationship and plan of care with an emphasis for the prevention of disease exacerbation and complications. * Educate members regarding shared decision-making tools to ensure the member is informed of all care options and potential harms and benefits. * Educate and empower members towards self-management while increasing quality of life. * Facilitate coordination, communication, and collaboration with the member and other stakeholders in order to achieve goals and maximize positive member outcomes. * Develop an understanding of and ensure compliance with accreditation requirements for standards related to DM/CM programs. * Maintain requirements of documentation as reflected in audits to meet compliance with quality standards and acknowledges patient's rights on confidentiality issues, always maintains patient confidentiality, and follows all HIPAA guidelines and regulations. * Refer to the medical director for any questionable, quality, or inappropriate treatment regimen and/or care. * Complete other projects, assignments, and duties, as assigned. 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. * Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization. * Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. 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 may 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 and two years of experience in a health maintenance organization or disease management organization. * Knowledge of Microsoft Office and internet software.