JOB PURPOSE Responsible for the oversight of clinical care management of community based long-term care population for PruittHealth Premier DSNP. Advises and coordinates clinical care across the health care continuum with community-based clinical providers and social support programs where PruittHealth Members receive support. Assists patients to achieve optimal health status using cost-effective, quality resources through model of care practice guidelines and Case Management (CM) Standards of Practice. Implements interventions to manage physical, psychological, social and financial barriers in cooperation with the patient, PruittHealth Premier, and medical providers. Position engages with members in both home and community-based settings.
KEY RESPONSIBILITIES
Conduct in-home and telephonic assessment and data collection with patients and caregivers; document findings concisely and comprehensively.
Develop a case management care plan for each patient based on history and clinical record review, including attending physician’s plan, national guidelines, social supports, and patient’s ability to comply.
Monitor patient and family needs on an ongoing basis and adjust the plan of care as changes occur.
Provide care management and coordination to ensure progression through the continuum of care and utilization of clinically appropriate, cost-effective resources per national practice guidelines and CM Standards of Practice.
Coordinate with the Plan Care Navigator/Member Advocate for integration of social service/support into patient care.
Coordinate hospital activities related to case management and discharge planning.
Ensure access to a range of choices, coordination of PCP and specialists, understanding of treatment plan and medications, identification of special needs and referrals, and coordination of transition between care settings.
Educate the patient and provide ongoing emotional support related to identified risk factors; empower the patient to take an active role in care.
Work with pharmacist and patient/caregiver to ensure medication therapy management and compliance.
Implement CM interventions using methods, techniques, behaviors, information and learning aids that positively impact the patient and condition.
Act as liaison between patient, PruittHealth Premier, caregivers, and other community health providers to ensure appropriate clinical oversight.
Schedule, coordinate, and complete interdisciplinary team activities with primary care and other members as appropriate (e.g., social workers, dietitians, pharmacologists, physician consultants).
Organize, secure, integrate and modify resources to achieve case management plan goals, in partnership with plan staff as needed.
Create quality CM reports documenting results of interventions and progress toward patient-specific goals.
Facilitate benefits preservation through coordination of appropriate level of care and plan compliance.
Facilitate recommended treatments with contracted providers to preserve benefits and support cost containment.
Help the participant understand available client benefits and local resources.
Adhere to PruittHealth Premier goals, objectives, standards of performance, and policies and procedures.
Ensure compliance with quality patient care and regulatory requirements within the company’s standards and RN scope of practice.
Comply with PruittHealth Premier’s confidentiality policy, HIPAA requirements and state and federal regulations.
Support the highest level of participant-defined quality of life and well-being.
Identify and participate in overall quality improvement activities.
Business travel may be required.
Ability to work in triage and/or disease management roles as needed.
Other duties as assigned.
KNOWLEDGE, SKILLS, ABILITIES
Ability to interact with a wide variety of people and handle complex situations with a customer service focus.
Creativity, integrity and initiative; attention to detail and follow-up.
Experience with electronic clinical charting/records; ability to work independently and in a remote environment.
Manage assigned caseload as business needs dictate; excellent time management and organizational skills; able to work independently and as part of a team.
Adherence to privacy, confidentiality, safety, advocacy, and accreditation/regulatory standards in all CM activities (office/remote).
Compliance with internal and external goals/metrics for the assigned department; ability to plan and prioritize patient care objectives.
Ability to analyze and problem-solve.
TECHNICAL SKILLS
Proficient computer skills in Windows, Care Management Platforms, and general Internet use.
Ability to chart and follow designated workflows in an electronic environment.
Proficient in typing.
COMMUNICATION SKILLS
Strong verbal and written communication skills to meet superior customer service and satisfaction levels.
Excellent interpersonal skills and ability to function as a member of a multi-disciplinary team.
Ability to communicate, read, and write fluently in English.
Effective analytical and problem-solving skills.
MINIMUM EDUCATION REQUIRED
Advanced Nursing Diploma and/or college degree in nursing required.
Bachelors (or higher) degree preferred.
MINIMUM EXPERIENCE REQUIRED
Minimum two years (full-time equivalent) direct clinical care experience required.
Minimum three years industry experience in a managed care setting focused on utilization review/case management; at least two years in CM, home care or hospice experience strongly preferred.
Minimum two years experience with long-term care population.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW
Licensed Registered Nurse with current, unrestricted license in state of practice (Georgia) required.
Certified Case Manager preferred – mandatory to apply for CCM certification when eligible.
Current CPR certification.
ADDITIONAL QUALIFICATIONS
Minimum of Class B driver’s license preferred.
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As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.