Summary

Works in collaboration with the Director of Care Coordination. Responsible for the development and implementation of a physician practice-based care coordination program working toward and achieving accreditation status as determined. Plays an important role in Population Health Management and care gap compliance. Oversees the Care Coordination staff embedded in the practices. Joint oversight of the Advanced Illness Management program along wit

Essential Duties and Responsibilities

• Supports and promotes the mission and values of Covenant Health Ministry.• Manages and coordinates clinical integration initiatives involving Care Coordination.

• Develops and manages an effective care coordination program.

• Assist with development of new initiatives that align with strategic plan goals

• Applies evidence-based principles in the development of care plans.

• Creates and maintains internal (SJHC) and external (specialists, community, payors, etc.)

resource databases.

• Coordinates upcoming accreditation efforts (medical home, etc.).

• Collaborates with System Director of Population Health on initiatives with payers for care gap compliance and reimbursement

• Collaborates with practice staff related to Patient Centered Medical Home requirements

• Serves as a lead clinical resource for clinical integration initiatives involving Care

Coordination.

• Provides initial and ongoing training and coaching to care team members.

• Works collaboratively with Transitional Care Management team to identify patients in need of focused care transition and care coordination services

• Works with care teams to develop systems and processes for the implementation and ongoing management of individualized care plans.

• Develops wellness and health coaching programs.

• Develops patient education materials.

• Recruits, trains, and supervises care coordinators in collaboration with management team.

• Oversight of High-Risk RN Care Coordinators and Advanced Illness-Palliative Care RN

• Completion of performance evaluations and stay interviews within defined timelines

• Maintenance of patient panels for High-Risk interventions

• Joint oversight of High-Risk Social Worker in the practice facilities

• Oversees collection, review, and submission of Population Health data

• Abstracts data from charts, payer portals and lists and enters date into proper place within patient charts to ensure information is accurate

• Organizes and interprets patient population, clinical and demographic data to determine care coordination needs and assists with identification of patients with special healthcare needs.

• Creates databases and electronic files to coordinate, track and manage program initiatives.

• Sends or transmits medical records as needed following HIM policy to support these initiatives.

• Utilizes reporting to identify high risk patients in need or priority practice outreach efforts.

• Provides metric-based performance feedback to care teams on an ongoing basis.

• Works collaboratively and effectively with the interdisciplinary team and community partners

• Assists with provision of seamless transition across the continuum of care

• Facilitates support groups for the community according to identified needs

• Maintains effective working relationships with community partners

• Serves as network representative with accreditation agencies

• Supports all provider committees committed to clinical integration initiatives

• Demonstrates strong ability to analyze problems and opportunities utilizing creative problem solving

• Documentation is timely, precise, and relevant

• Demonstrates ability to organize workload and set appropriate priorities

• Maintains current knowledge of organization’s policies and procedures.

• Maintains clinical competence in relation to Nursing and Care Coordination

• Maintains/enhances professional development and personal growth required to perform as a Registered Nurse and to fulfill organizational requirements.

• Participates in peer review with team members

• Achieves annual goals

• Participates in peer review with team members

• Identifies high risk patients & families and makes referrals to the Quality and Risk

Management functions.

• Stays current with DNV & CMS regulations

• Assists in writing policies, memos, and patient/family education material as assigned.

• Assists in the planning and development of programs and special projects.

• Serves on assigned hospital committees.

• Performs various assignments as requested by the Director of Care Coordination.

• Other duties as consistent with this role

Job Requirements

Job Knowledge and Skills

• Excellent communication skills

• Computer skills

• Strong interpersonal skills enabling effective team collaboration

• Positive attitude

• Strong organization and time management skills

• Ability to work independently

• Ability to work remotely as needed

• Knowledgeable and skilled with relational databases and Microsoft Office

Education and Experience

• Current New Hampshire RN license required

• BLS/CPR, AED certification required

• Certification as CCM and/or ACMA-RN preferred

• BSN preferred

• 5 years nursing experience preferred

• 2 years care coordination experience preferred

An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.

Working Conditions/Physical Demands

Must possess the physical and mental abilities to perform the tasks normally associated with this position that involves a combination of sitting, standing, walking, bending, stooping, and reaching. Lifting/carrying frequently up to 35 pounds, and occasionally up to 50 pounds. Some stress related to high level of responsibility for quality care.

Americans with Disabilities Statement

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Covenant Health reserves the right to modify position duties at any time, to reflect process improvements and businessnecessity