· Serves as the primary person to provide community-based support services and care gap closure to all Amerihealth Caritas Health Plan (ACHP) patients and follow up on results.

· Identifies members with care gaps through the use of the gaps in care lists from Navinet and the Quality Enhancement Dashboard.

· Provides education on chronic conditions, assistance, or referrals as needed.

· Provides Diabetes Self-Management Education (DSME).

· Assists with care coordination (i.e., medical/dental appointments, labs/radiology, DME, D/C).

· Serves as a liaison between BCHC ACHP patients and primary care team.

· Coordinates with each new and existing ACHP patient to establish and maintain relationships.

· Ensures continuity of care through ongoing communication with the entire team, ACHP patients and caregivers if appropriate.

· Collaborates with the ACHP patients/families to assist with individualized care planning, including preventative care and screening.

· Assesses and addresses barriers when ACHP patients have not met treatment goals via whatever method serves the patient best; written, oral and in appropriate language.

· Develops, implements and documents tracking activities associated with Patient Centered Medical Home (PCMH).

· In conjunction with other care team members, tracks all screening needs and gaps in care that create a barrier to overall quality of health.

· Follows up on referrals and all other high priority issues identified by the PCP.

· In conjunction with the Primary Care Provider (PCP) actively promotes patient and family engagement.

· Respects the centrality of the patients/families as core members of the health care team.

· Examines how the safety, quality and cost effectiveness of health care can be improved through the active involvement of ACHP patients and families.

· Examines common barriers to active involvement of ACHP patients in their own health care processes and assists to reduce barriers, when possible, through the use of the entire care team

· Utilizes strategies to empower ACHP patients or families in all aspects of the health care process.

· Develops and implements strategies to collaborate with ACHP patients, providers, families, and caregivers to enhance continuity of care and effective utilization of health care resources.

· Defines and maintains coordinated care strategies between BCHC and other inpatient and outpatient health care providers aimed at improving patient health.

· Assists with referral coordination and medication reconciliation.

· Identifies appropriate resources within BCHC and the community to support patient self-management.

· Develops and documents self-management plans and goals related to screening measures.

· Encourages participation in BCHC-based education and support programs.

· Refers patient to community-based support and education programs, community resources, behavioral health, and drug and alcohol treatment as appropriate.

· Participates in Morning Huddles at times, providing direction and assistance to other members of the Clinical Support Team as needed to improve efficiency and productivity of the meetings.

· Coordinates with community resources to provide patient education, outreach, and preventative health programs.

· Develops and provides patient education.

· Acquires pertinent patient history from the ACHP patient and/or significant interim items prior to patient appointments.

· Completes and documents all interventions and outcomes.

· Enters all necessary documentation, ensuring accuracy and completeness, required for billing, quality, and safety initiatives.

· Submits reports on a monthly basis to ACHP regarding key data points.

· Other responsibilities that become incorporated into the BCHC/ACHP RN Model.

· Participates in activities aimed at increasing the visibility of BCHC in community-wide health care initiatives.

Knowledge, Skills and Abilities

Education and Requirements

• Graduate of an accredited RN program

• Active Pennsylvania Nursing License

• BLS certification

• Certified Diabetic Educator Preferred

• Bilingual skills (Spanish) preferred

Key Competencies

• Demonstrable knowledge base to successfully function within the position.

• Ability to utilize EMR and Practice Management system.

• Proficient with Microsoft Office products (Word, Excel, PowerPoint) and Microsoft Outlook.

• Ability to prioritize, multitask, meet deadlines in a fast-paced, high-volume setting.

• Actively embraces change and identifies strategies to help self and others function well amidst change.

• Exceptional team building skills, including conflict resolution capabilities, shared decision making, and transparency in communication.

• Flexible to meet changing departmental needs.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Paid time off
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Education:

• Associate (Preferred)

Experience:

• Nursing: 1 year (Required)

License/Certification:

• BLS Certification (Required)
• RN (Required)

Work Location: In person