- The Care Coordinator supports the primary/specialty care physicians in population health management by focusing care coordination attention on the high to moderate risk, chronic condition population driving utilization and costs to improve efficiency, quality and patient satisfaction.
- Engages physician and practice team in proactive patient management by addressing medical and behavioral health care needs, follow-up, and referrals. Utilizes high risk registry, Hospital census reports and other reports provided by the MCOs to outreach to targeted population benefiting from care management program.
- Offers and coordinates care consultation to complex patient/caregiver in the practice setting or home as necessary to reinforce disease management education utilizing teach back methods or assist with completion of health care proxy, advanced care planning, or community resource navigation.
- Develops comprehensive care plans in collaboration with physician and health care team based on evidence-based best practices for chronic illness care. Participates in creation of a patient-centered care plan that addresses problems /barriers/goals and develops action plan relevant to obstacles in chronic condition management. Provides resources to appropriate community resources and support programs, and ensures that patients are able to access and follow through on these referrals.
- Ensures assessment and comprehensive care plans are completed/signed by provider within required time frame in compliance with CAMC HEALTH NETWORK standards. Adheres to all CAMC HEALTH NETWORK policy and MCO partner requirements.
- Serves as a central resource for the physicians and practice team for the CAMC HEALTH NETWORK population functioning as navigator, coach, and disease manager for the targeted patient population. Collaborates with patients to facilitate healthy behaviors. Utilizes coaching to foster healthy diet, exercise, medication and disease management. Helps patients to learn strategies and skills designed to stabilize symptoms and prevent disease progression. Works closely with the community health worker to provide ongoing patient support reinforcing the care plan.
- Reviews high cost patients with physician and/or primary care team to understand drivers of cost, current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals are addressed such as palliative/hospice and makes recommendations for cost reduction alternatives whenever appropriate.
- Analyzes retrospective/concurrent utilization and cost data and seizes opportunity to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximizing organization performance.
- Interfaces regularly with patients, families, assigned physicians, the health care team, community agencies, vendors, MCO partners, Community Partners, and hospital staff as necessary to ensure efficient, quality care delivery.
- Reviews high risk cases with Manager of Care Management, Medical Director as appropriate, and physicians in a concise, effective, professional manner. Addresses medical /and or psychosocial concerns and makes recommendations to improve efficiency and quality care. Serves as a resource to physicians, provider care team, and patient/family regarding inpatient/outpatient resources.
- Documents in the case management system the assessment and clear, concise, timely notes that address patient medical/psychosocial problems, barriers, goals, support system, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost.
- Post High School Diploma or Certificate Program (Required)
- Drivers License (Required)
- Licensed Practical Nurse (Required)
- Basic Life Support (Required) Within 30 days of hireWithin 30 days of hire
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Surgical Tech 2 LPN-PH - Greenbrier, United States - CAMC Health System
Description
Job Summary
Provision of assistance to the Staff and to the needs of the physician in providing patient care under the supervision of a Clinical Nurse.
Responsibilities
Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages.
Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6.Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.Education
Credentials
Status: Full Time Regular 1.0
Location: Greenbrier Valley Medical Center Maplewood
Location of Job: Greenbrier Valley Med Ctr
Talent Acquisition Specialist:
Jamie.
Douglas
