Job Description: Registered Nurse or Master Social Work (Job Descriptions for Both Roles Below) Registered Nurse Position Summary: Responsible for providing a variety of Care Coordination services within the Primary Care (PC) practice setting, for members that are considered at risk and/or who experience barriers to healthcare. Principle Care Coordination services include, but are not limited to, performing comprehensive assessments, focusing on member-centered care planning, providing episodic and longitudinal care planning, monitoring acute facility stays and discharges, facilitating disease education groups, individual disease education, empowering member’s self-management skills and understanding of their medical condition, and referring members to appropriate community resources. COMPETENCIES/Role-Specific Functions: COMMUNICATION Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills. Communicate assessment findings, care plan goals, interventions and outcomes to PC providers in a timely manner. Develop, communicate and implement care plans in coordination with members, caregivers, providers and care teams. Participate in Care Rounds, or similar type meeting, at the practice to furnish member reports and updates to care team and collaborate on care plans and strategies. Actively engage PC providers and staff in identifying high risk members and collaborate with providers and care teams on methods for navigating members’ care successfully along the care continuum. Communicate with all internal Physician Health Partners (PHP) departments effectively to result in optimal meeting of business needs. Communicates and collaborates appropriately to seek guidance and direction with management when necessary. PROBLEM SOLVING Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. Complete comprehensive assessments to identify needs and barriers to member’s ability to manage their medical conditions and treatment plans. Pursue appropriate medical and/or staff intervention in a timely manner to assure problem resolution. Provide crisis intervention services. Collaborate with peers, management and other appropriate resources on complicated situations. Displays Strength-Based Approach to collaborative problem solving. PRODUCTIVITY Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow. Document member information, contacts and interventions in applicable care management software systems utilizing PHP Care Coordination Standard Operating Procedures. Actively identifies opportunities to enhancement, lean processes and overall improved delivery of Care Coordination services. Strategically approaches the practice(s) with the goal of achieving optimal practice engagement, effective care coordination and collaboration to maximize positive member outcomes. Contribute to the Care Coordination team through staff meeting attendance and participation, lending assistance to co-workers, participation on committees, LEAN events and other PHP similar activities. SELF DEVELOPMENT Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities. Has ability to receive feedback and apply it to work performance. Encourages others on the team surrounding their own self development. Demonstrates an understanding of current healthcare trends. Fulfills requirements necessary to maintain licensure. Identify opportunities for, and participate in, continuing education including workshops, conferences, specific publications, etc. CUSTOMER FOCUS Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers. Develop and maintain effective professional working relationships with assigned PC Practice(s) setting of providers, the members, care-givers, families and community resources. Identify and support practice needs for structured on-site Care Coordination presence in alignment with program models. Participate in practice meetings such as Quality and Provider Relations, as instructed by PHP Manager. Develop and maintain professional and effective working relationships with all PHP internal customers. Within the PC practice setting, develop and implement documented strategies for improving care coordination integration. JOB KNOWLEDGE Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. Identify members that would potentially benefit from Care Coordination services, by using a variety of data sources, including but not limited to, high risk and utilization reports, prior authorization services, physician/practice referrals, referrals from other sources and practice EMR stratification data. Complete visits with members, their caregivers and significant others in potentially a variety of settings, determined by program models and initiatives. Provide evidence based crisis intervention services. Employ motivational interviewing skills to elicit optimal member engagement/outcome. Complete required HIPAA training and maintain confidentiality through compliance with regulations and company policy. Perform comprehensive, accurate, and appropriate assessments that support individual member needs while identifying and addressing barriers. Communicate goals, interventions and outcomes and other pertinent updated to PC physicians in a timely manner. Demonstrates consistently, strong ethics and sound judgement. Maintain a core understanding of population management as it specifically relates to high risk members. Utilize behavioral health screening assessments, identify symptoms of behavioral health and substance abuse concerns, and effectively make referrals to appropriate community resources. Maintain a working knowledge of community resources to address a wide variety of psychosocial needs members may experience. Other duties as assigned. Qualifications (Education/Experience/Knowledge/Skills/Abilities): RN or LVN with valid license in good standing. (Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures) Experience working with high risk DSNP, CSNP Complex member and Medicaid, preferred A minimum of one year of case management experience or a combination of relevant experience, in the fields of healthcare or behavioral health. Experience with assisting patients through transitions on the care continuum. Experience managing psychosocial issues with patients and families Knowledge of case management, community resources/agencies, program and workflow development, and process improvement. Accept and work with diverse populations, preferably within the designated region, (age, ethnic groups, socio-economic levels, etc.) and provide culturally sensitive coaching, education and assistance to members and their families. Collaborate with community based resource agencies to effectively manage members. Ability to resolve community resource issues in a creative, positive and timely manner to improve clinical outcomes of members. Experience in conflict management and problem resolution. Skilled in Motivational Interviewing. Skilled in developing and maintaining positive relationships and communicating effectively with internal and external customers. Participate in program development in order to identify appropriate goals of program. Adapt quickly to changing demands in the healthcare industry. Coordinate and/or facilitate meetings. Perform intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, and Power Point. A valid unrestricted Texas drivers’ license. (if applicable) Reliable and insured vehicle. (if applicable) Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures. Mobile Device for work purposes as defined by the company policies and procedures. (If applicable) Care Coordinator- Social Work Position Summary: Responsible for providing a variety of Care Coordination services within the Primary Care (PC) practice setting, for members that are considered at risk and/or who experience barriers to healthcare. Principle Care Coordination services include, but are not limited to, performing comprehensive assessments, focusing on member-centered care planning, providing episodic and longitudinal care planning, monitoring acute facility stays and discharges, facilitating disease education groups, individual disease education, empowering member’s self-management skills and understanding of their medical condition, and referring members to appropriate community resources. COMPETENCIES/Role-Specific Functions: COMMUNICATION Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills. Communicate assessment findings, care plan goals, interventions and outcomes to PC providers in a timely manner. Develop, communicate and implement care plans in coordination with members, caregivers, providers and care teams. Participate in Care Rounds, or similar type meeting, at the practice to furnish member reports and updates to care team and collaborate on care plans and strategies. Actively engage PC providers and staff in identifying high risk members and collaborate with providers and care teams on methods for navigating members’ care successfully along the care continuum. Communicate with all internal Physician Health Partners (PHP) departments effectively to result in optimal meeting of business needs. Communicates and collaborates appropriately to seek guidance and direction with management when necessary. PROBLEM SOLVING Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. Complete comprehensive assessments to identify needs and barriers to member’s ability to manage their medical conditions and treatment plans. Pursue appropriate medical and/or staff intervention in a timely manner to assure problem resolution. Provide crisis intervention services. Collaborate with peers, management and other appropriate resources on complicated situations. Displays Strength-Based Approach to collaborative problem solving. PRODUCTIVITY Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow. Document member information, contacts and interventions in applicable care management software systems utilizing PHP Care Coordination Standard Operating Procedures. Actively identifies opportunities to enhancement, lean processes and overall improved delivery of Care Coordination services. Strategically approaches the practice(s) with the goal of achieving optimal practice engagement, effective care coordination and collaboration to maximize positive member outcomes. Contribute to the Care Coordination team through staff meeting attendance and participation, lending assistance to co-workers, participation on committees, LEAN events and other PHP similar activities. SELF DEVELOPMENT Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities. Has ability to receive feedback and apply it to work performance. Encourages others on the team surrounding their own self development. Demonstrates an understanding of current healthcare trends. Fulfills requirements necessary to maintain licensure. Identify opportunities for, and participate in, continuing education including workshops, conferences, specific publications, etc. CUSTOMER FOCUS Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers. Develop and maintain effective professional working relationships with assigned PC Practice(s) setting of providers, the members, care-givers, families and community resources. Identify and support practice needs for structured on-site Care Coordination presence in alignment with program models. Participate in practice meetings such as Quality and Provider Relations, as instructed by PHP Manager. Develop and maintain professional and effective working relationships with all PHP internal customers. Within the PC practice setting, develop and implement documented strategies for improving care coordination integration. JOB KNOWLEDGE Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. Identify members that would potentially benefit from Care Coordination services, by using a variety of data sources, including but not limited to, high risk and utilization reports, prior authorization services, physician/practice referrals, referrals from other sources and practice EMR stratification data. Complete visits with members, their caregivers and significant others in potentially a variety of settings, determined by program models and initiatives. Provide evidence based crisis intervention services. Employ motivational interviewing skills to elicit optimal member engagement/outcome. Complete required HIPAA training and maintain confidentiality through compliance with regulations and company policy. Perform comprehensive, accurate, and appropriate assessments that support individual member needs while identifying and addressing barriers. Communicate goals, interventions and outcomes and other pertinent updated to PC physicians in a timely manner. Demonstrates consistently, strong ethics and sound judgement. Maintain a core understanding of population management as it specifically relates to high risk members. Utilize behavioral health screening assessments, identify symptoms of behavioral health and substance abuse concerns, and effectively make referrals to appropriate community resources. Maintain a working knowledge of community resources to address a wide variety of psychosocial needs members may experience. Perform other duties as assigned. Qualifications (Education/Experience/Knowledge/Skills/Abilities): MSW required LSW or LCSW with valid license in good standing preferred. (Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures) Experience working with high risk DSNP, CSNP Complex member and Medicaid, preferred A minimum of one year of case management experience or a combination of relevant experience, in the fields of healthcare or behavioral health. Experience with assisting patients through transitions on the care continuum. Experience managing psychosocial issues with patients and families Knowledge of case management, community resources/agencies, program and workflow development, and process improvement. Accept and work with diverse populations, preferably within the designated region, (age, ethnic groups, socio-economic levels, etc.) and provide culturally sensitive coaching, education and assistance to members and their families. Collaborate with community based resource agencies to effectively manage members. Ability to resolve community resource issues in a creative, positive and timely manner to improve clinical outcomes of members. Experience in conflict management and problem resolution. Skilled in Motivational Interviewing. Skilled in developing and maintaining positive relationships and communicating effectively with internal and external customers. Participate in program development in order to identify appropriate goals of program. Adapt quickly to changing demands in the healthcare industry. Coordinate and/or facilitate meetings. Perform intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, and Power Point. A valid unrestricted Texas drivers’ license. (if applicable) Reliable and insured vehicle. (if applicable) Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures. Mobile Device for work purposes as defined by the company policies and procedures. (If applicable) Salary Range: RN $65,711 – $82,139 SW $58,510 - $73,137 Alpine is growing, and we welcome new talent to our highly collaborative and diverse team. We are passionate about building a leading national organization that enables physicians to focus on the joy of practicing medicine, and supports the ongoing transition to value-based care for senior populations. Alpine brings this same level of passion to employee engagement, career development and progression. If this aligns with your career goals, then look no further. Grow with us!