Job Duties:

Interact with patients both telephonically and in person to serve the daily case management needs of patients.

Act as a comprehensive care coordinator for assigned patients, develop interventions, assess the patient's need accordingly and facilitate communication amongst other providers caring for the patient.

Assess physical, emotional, psychosocial, and environmental needs of the patient within scope and capabilities of clinical background.

Develop collaborative partnership with providers caring for the patient through frequent telephonic and/or in person interactions with the provider and office staff.

With physician guidance develop interventions and processes to assist the patients in meeting short and long term goals.

Creates daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department. Provides follow up communication to patients and Care Coordination team.

Coordinate patient visits with PCP and specialists as needed.

Adjust interventions in a manner that is sensitive to different cultural, religious, economic, and social groups and how it affects the knowledge, delivery, and acceptance of healthcare services.

Coordinate episodic care to eliminate unnecessary costs and ensure optimal outcomes.

Maintain accurate and timely documentation in the care management system and provide regular feedback to patients' PCPs.

Works toward continuously improving quality metrics and closing care gaps. Supports clinicians in achieving quality incentives.

Other duties as assigned.

Requirements:

Knowledgeable of healthcare quality programs including Medicare Access and CHIP Reauthorization Act (MACRA), Comprehensive Primary Care (CPC ), Merit Based Incentive Program (MIPS), Physician Quality Reporting System (PQRS), Value Based Payment Modifier (VBPM), Patient Centered Medical Home (PCMH), Comprehensive Primary Care initiative (CPC initiative) and Patient Centered Specialty Practice (PCSP) preferred.

Knowledge of AccountableCareOrganization(ACO) and function

·Current Certified Nursing Assistant (CNA), Certified Medical Assistant (CMA), or Licensed Practical Nurse (LPN) preferred or Associates Degree/Bachelor's Degree in Science with Clinical/Medical concentrationnical experience in an acute care hospital, physician office or managed care case management or utilization review department is preferred.

Minimum 2-3 years' clinical experience in an acute care hospital, physician office or managed care case management or utilization review department is preferred.

 Ability to develop strong, successful, and responsive relationships with clinical team that is quality oriented and focused on customer service.

Ability to communicate clearly and effectively through both speech and writing.

· Ability to think creatively and strategically and develop innovative solutions to challenging problems.

·Exceptional interpersonal and communication skills with a strong ability to motivate and multi-task.

·Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, and the ability to learn other software as needed. Experience and knowledge of electronic health records (Athena Preferred) and data analytics preferred.

·Ability to generate and analyze reports or ability to learn

·Bi-lingual preferred

Additional information

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required.
• This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company's rights to assign or reassign duties and responsibilities to this job at any time.
• Shore Physicians Group is an Equal Opportunity Employer. All applicants will receive consideration for employment without regard to sex, affectional or sexual orientation, gender, gender identity, orientation or expression; marital status, domestic partnership status, civil union status, pregnancy, race, creed, ancestry, color, ethnicity, national origin, age, disability, religion, genetic information, or veteran status or any other basis prohibited by law.