Centralized Programs Care Coordinator- LVN/RN
1 day ago
A new opportunity awaits a Centralized Programs Care Coordinator- LVN/RN at one of our busy medical sites, Community Medical Providers (CMP) with Sante Health System in Fresno, CA. This position is responsible for collaboration with site staff, physicians, and management to perform and achieve objectives of the Chronic Care Management program for all eligible patients according to insurance guidelines, as well as the patient centered medical home (PCMH) by coordinating medical management to ensure quality, cost effective care for patients with complex medical conditions to reduce ED and in-patient admissions and to improve health outcomes while ensuring quality metrics are met and reimbursements are captured. Promotes patient engagement and satisfaction, increased physician and staff satisfaction and maximizes the use of available resources.QUALIFICATIONSGraduation from an accredited school of nursing, required. Minimum of five years of professional experience in an ambulatory clinic or hospital setting. Must possess an active State Registered RN or LVN license.ESSENTIAL DUTIES AND RESPONSIBILITIESComplete comprehensive age-appropriate initial assessment based on patient strengths, goals and needs, acute and chronic health conditions, environment, and psychosocial determinants of health. In consultation with the patient, physicians, and other care team members, develop a proactive care plan and efficient process for Chronic Care Management (CCM) and Patient Centered Medical Home (PCMH) Ensures that CCM care plans and monthly calls are coded accurately for maximum financial capture. Conduct concurrent and ongoing reviews of patient documentation in the medical record. Work directly with involved parties regarding verification of benefits and eligibility for medical necessity and identification of eligible patients for CCM and PCMH programs. Conduct ongoing assessments to determine response to care plan or services and/or changes in patient's biophysical, psychosocial, family, or environmental status. Reprioritize care plan based on new information and update patient care plan and assure patient, family and care team members who participate are informed of updated plan. Generate statistical reports. Maintain patient demographics, list of patient problems and diagnoses including problems not currently being managed for reference. Track patient's medications and lab results and manage short-term/long-term goals and challenges. Track case interventions and case outcomes. Schedule calls and appointments as required. Maintain call notes, patient files, records, and other information. Maintain integrity of data security in compliance with HIPAA requirements. To assist and provide education to staff and physicians in resolving questions or problems involving patient treatment plans, serving as the primary advocate and liaison between Primary Treating Physician, care team members and third-party providers. Maintains the sustainability and process improvement for CCM and makes referrals as appropriate. Assist in developing an appropriate hospital discharge plan and coordinating home health, skilled nursing facilities, rehab centers and durable medical equipment needs for the patient upon discharge. Follow discharged patients with care coordination to include phone calls for transition of care and notification to the patient's physician and care team. Attend required meetings and to participate in committees as requested. Participate in professional development and maintain professional affiliation. Maintain strictest confidentiality in compliance with HIPAA regulations. Provide EPC and CCM services under the direction of a physician. In the spirit of teamwork, employees are expected to follow any other job-related instructions and to perform any other job-related duties as requested. ABOUT SANTE HEALTH SYSTEMSante Health System is a Management Services Organization that serves multiple clients. "Sante" is the French word for health. Our name symbolizes our commitment to good health, progressive care, and leadership in our community.Sante is one of the largest healthcare claims and billing management companies in Central California. The strength of Sante is the extraordinary network of physicians, health plans, and other health service providers it offers the people of our valley. Sante coordinates with physicians, health plans, hospitals, and ancillary providers to ultimately benefit the patient in a managed care environment. Sante Health System provides numerous client services such as billing, claims processing, contracting, credentialing, finance, human resources, information services, marketing/communications, physician services, practice management, provider relations, quality improvement, and utilization management.Sante is celebrating over 25 years of dedicated service to the community. We deeply understand that we would not be successful in enhancing the quality of life of our patients without our incredible team. This is why we have created a work culture that is comprised of talented, driven, dedicated, innovative, and service-driven professionals. We provide competitive pay, excellent benefits including medical, dental, vision, and life insurance, 401k retirement plan, paid time off, and opportunities for advancement. Being part of our team is like being part of a big family. Join our team and make Sante Health System your home away from home.ARE YOU READY TO JOIN OUR TEAM?If you feel that you are right for this position, apply now We look forward to meeting you Apply today
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