Exhibits a commitment to the mission and goals of the organization and demonstrates a respect for working in a collaborative decision-making process by incorporating continuous quality improvement. Gathers and analyzes specific criteria and guidelines to track and manage inpatient high risk admissions, avoidable ED visits, readmission and high cost utilization of the PHO members. Ensures the appropriate delivery of services through Assessment and Case /Problem Identification, Coordination, Planning, Monitoring and Evaluation. Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources insuring appropriate utilization across the continuum of care. Communicates in a clear and effective manner with members, their families, caregivers, physicians and other health care personnel. Communicates in a clear and effective manner with members of varying educational levels, backgrounds and cognitive levels. Shows empathy and compassion in case managing our members; makes every effort to understand the circumstances affecting the member and their health care and vested interest in the wellness of the member. Works with the members on realistic goal setting while incorporating socio-cultural ethnic factors, support and facilitate members to move towards achieving their goals. Accommodates the member’s preference for mode for patient education and coaching such as telephonic, in-person or video conferencing. Initiates an in-person visit with the member based on established case management standards of care and protocols. Assess the member’s home environment to identify potential risks and barriers to the health and wellness and makes appropriate referrals as needed. Adheres to defined plan of care and adjusts the plan as appropriate based on the member’s status and information collected upon reassessment. Collaborates with, and is responsible for, coordination with other disciplines participating in the Plan of Care (i.e. PCP, Specialist, Dietician, VNA, SNF/Rehab personnel, community resources). Participates in multi-disciplinary patient case conferences; evaluates the effectiveness of patient care. Reassesses the plan of care at regular intervals and discharges the member when goals are met. Notifies the Primary Care Physician (PCP) and other care providers in a timely manner of significant changes in the member’s condition or care plan. Documents the member’s care in the case management systems including the development of a collaborative plan to be shared and updated with the risk member’s clinical team such as the PCP and/or Specialists. Documentation is timely, clear, concise, and addresses specifics of teaching and care coordination. Follows the PHO’s documentation protocols to collect pertinent data supporting performance and success measures. Maintains medical records and medical information in a confidential manner appropriate to legal requirements and standards of good practice. Regularly meets with the PHO Helping Hands team and the Medical Director as needed for care collaboration, coordination and team support. Maintains core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities. Participates in PHO-related committees, education programs, in-services, and meetings as required. Demonstrates flexibility, cooperation and characteristics of a team member. Collaborate with Case Managers at Hospitals on large case management and discharge planning. Performs other related duties as assigned or requested to meet the scope of the organization’s mission.
Current license as a Registered Nurse in the Commonwealth of Massachusetts. Bachelor of Science Degree in Nursing preferred. Certificate in Case Management preferred.
Demonstrates competency with a minimum of experience of 3 years in a hospital setting, home health care or outpatient Physician Office setting.
Demonstrate recent knowledge/experience within past 3 to 4 years in: Discharge Planning; Utilization/quality management; Home care and/or Hospice Nursing.
Ability to speak effectively before individuals and groups of patients or employees of the organization.
Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies.
Excellent organization and time management skills.
Possess skills in independent decision-making, problem-solving, independent judgement, use of critical thinking and effective communications.
Ability to work independently and effectively in a fast-paced environment.
Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
Proficient computer skills with the ability to utilize and integrate information from multiple software and EHR systems.
