ESSENTIAL DUTIES AND RESPONSIBILITIES:

• 45% Fosters strong professional relationships with members of a patient’s Medical Neighborhood to facilitate the coordination of referrals and ensure quality services/products are received in the most cost effective manner. Collaborates with patient clinical site to include providers and other team members in an effort identify the targeted population within his/her practice site and risk stratifies all members to prioritize needs and direct interventions. Works in partnership with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.

Designs an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, their support system, primary care provider, and other members of the health care team to ensure coordination of services.

• 25% Works with xG Population Health Management leadership to continuously evaluate process, identify problems, and propose process improvement strategies to enhance the Medical Home delivery of care model. Utilizes appropriate conflict resolution, assertiveness, negotiation, and collaboration skills in facilitating Patient/family throughout the health care continuum.

• 20% Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population. Maintains required documentation for all case management activities. Collects required data and utilizes this data to adjust the treatment plan when indicated. Manages utilization and practice metrics to further refine the delivery of care model to maximize clinical, quality, and fiscal outcomes.

• 5% Implements and delivers clinical interventions based on risk stratification and evidence-based clinical guidelines utilizing various modes of delivery to include telephone communication, primary care site, or patient home visits.

• 5% Develops and Implements systems of care that facilitate close monitoring of high-risk members to prevent and/or intervene early during acute exacerbations.

NON-ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Coordinates appropriate laboratory and diagnostic testing.
• Assesses the healthcare, educational and psychosocial needs of the patients and family.
• Reviews the current literature regarding effective engagement and communication strategies, case management strategies and behavior change strategies and incorporates into clinical practice.
• Adheres to xG Administrative standards regarding member confidentiality.
• Performs duties usually within call center, and/or physician practice location.
• Performs duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform

SKILLS AND ABILITIES:

• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

• Reveals ability to work autonomously and be directly accountable for results.
• Exhibits the capability to influence and negotiate individual and group decision-making.
• Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into case management practice.
• Possess the skill to function effectively in a fluid, dynamic, and rapidly changing environment.
• Displays the proven ability to positively influence behavior and outcomes.
• Protects confidentiality of data and intellectual property; insures compliance with national health information projection guidelines.
• Serves as a role model for education and professional nursing practice
• Demonstrates proficient computer knowledge with proven keyboarding skills.

EDUCATION AND/OR EXPERIENCE:

• Requires Registered Nurse with current license. Certification in Case Management required within three years of hire. Must maintain such certification throughout employment.

• BSN or comparable Bachelor’s degree preferred.
• Minimum of three years recent experience to match responsibilities above such as acute care, home health or skilled nursing facility with a demonstrated working knowledge of Medicare/PPS/MDS guidelines required. Experience as a Case Manager PCHM preferred.
• Experience with IT solutions such as electronic health record, learning management or disease/case management systems a plus.
• Critical thinking skills and ability to analyze complex data sets required. General computer knowledge and
• capability to use computers required.
• Experience with IT solutions such as electronic health record, learning management or disease/case management systems a plus.