STATUS: Full Time

LOCATION: Massena Hospital

DEPARTMENT: Behavioral Health

SCHEDULE: M-F, 8am-4pm

ATTRIBUTES

• 3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.

• Experience with Patient-Centered-Medical Home desirable.

• Completion of an accredited Registered Nurse training program. BSN preferred.

• Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment required.

• Chronic Disease Self-Management Certification required within 12 months of employment.

• Willingness to obtain ongoing and up to date population specific education

RESPONSIBILITIES

• Care Coordination: Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.

• Provides assessment, care planning and coordination, and advocacy to patients and their families.

• After assessing the health status of patients, develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.

• Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.

• Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.

• Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.

• Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.

• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.

• Promote timely access to appropriate care.

• Increase utilization of preventative care.

• Reduce emergency room utilization and hospital readmissions.

• Increase comprehension through culturally and linguistically appropriate education.

• Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).

• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.

• Tracks and reports on patient progress.

• Manage referrals, when needed, to appropriate agencies required to assist the patient in achieving the goals and objectives defined in their Care Plan.

• Defines and directs patients and/or families to appropriate resource utilization.

• Increase patients’ ability for self-management and shared decision-making.

• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, reduce social barriers to care, and decrease health care costs.

• Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g. request interpreters as appropriate, transportation services, or prescription assistance.)

• Assist with data collection and generation of patient registry reports.

• Attends and participates in team/educational conferences as needed.

• Care Delivery: Maintains safe and effective nursing care rendered directly or indirectly, adjusting nursing care processes as necessary to ensure optimal patient care.

• Triage patient phone calls.

• Provide medication reconciliation.

• Pre-Visit planning prior to physicals of patients identified in registry.

• Performs RN-Led Annual Wellness Visits

• Make adjustments in patients' medications following physician directed guidelines to achieve therapeutic levels. Evaluates patient response to those interventions.

• Placing orders for lab tests, immunizations or ancillary testing per protocol, under provider guidance.

• Assist & manage follow-up care as requested by Primary Care physician.

• Leads patient care team in daily and/or weekly huddle discussions to prepare for the day or week ahead.

• Works closely with community resources to coordinate care needed by high risk patients, as defined by the practice.

• Under direction of practitioners, communicate test results and care plans to patients/families.

• Assists and completes various forms for the patient.

• Responsible for coordinating and leading patient support groups and/or shared medical appointments.

• Quality & Regulatory: Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.

• Works with PPM management team to comply with all established standards and regulations per DNV standards and hospital compliance requirements.

• Works with PPM management team to resolve clinical issues (processes, performance, etc.) to identify opportunities for improvement.

• Adheres to CPH and PPM policies and procedures, protocols, guidelines, etc.

• People: Serve as a mentor and a resource provider for clinic and hospital staff.

• Provide education to patients and significant others, as well as staff.

• Maintains a level of communication that exceeds the person’s expectations in every encounter.

PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

LICENSES/CERTIFICATIONS:

• BLS - Basic Life Support - American Heart Association (AHA)

PAY RANGE: $65,000.00 - $90,100.00