Essential Functions:
- Proactive outreach to high risk members identified through claims data
- Develops personalized treatment plans using provider care plans and member preferences
- Supports “Individual contributor to” a proactive, multidisciplinary team approach directed toward prevention, education and health promotion
- Establishes supportive relationship with members
- Assesses member’s educational/clinical/social needs, prioritizing care based on elicited information from the member, Epic, and data analysis
- Acts as resource for members
- Documents touchpoints and progress into the electronic medical record
- Collaborates with the full scope of clinical team members to arrange for further medical treatment when needed
- Provide support and tools needed to help members take control of their health
- Delivering exceptional member experiences and engaging members in their healthcare journeys
- Improving health outcomes and better management of any chronic condition
- Lowering healthcare costs while improving outcomes
- Consults with other members of the healthcare team to solve problems and seek advice
- Works closely with client’s vendors as appropriate to support member’s needs
- Identifies emergency situations and provides care within legal scope of practice
- Maintains member privacy and confidential member information
- Participates in outreach/follow-up phone calls and follow-up member visits
- Assists in the development of criteria to measure outcomes, assists in the analysis of data for quality improvement, interprets study results, identifies limitations and barriers and recommends alternatives
- Provides condition specific self-care education to client employee enrolled in the various condition management programs
- Serves as member advocate
- Acts as facilitator of Care Team meetings.
- May require other duties as assigned. Designs interventions with the member to improve outcomes
- Coaches effectively virtually using video and phone
- Collaborates with health center staff to coordinate and promote health and wellness programs
- May assist Operations in assessing and maintaining reports, evaluating clinical program(s) & conducting ongoing evaluation of the effectiveness of the programs
- Develops and presents educational services for associated persons or departments as appropriate
- Currently licensed Registered Nurse in state of practice
- Current certification AHA or ARC Basic Life Support for health care providers
- Bachelor's degree (BSN) from four-year college or university (preferred)
- At least three years’ experience as a Registered Nurse caring for members with any of the following conditions: Type 2 diabetes, asthma, heart disease, heart failure or hypertension.
- Experience in Condition Management, Certificate in Case Management, Care Coordination, Certified Diabetes Educator (CDE) Certified Diabetes Care and Education Specialist (CDCES) a plus
- Certified in an ICF-accredited coaching program (preferred)
- Understanding of data analysis in a healthcare environment
- Knowledge and experience with Electronic Medical Records (preferred)
- Multiple state licensure preferred.
Premise Health is an equal opportunity employer; we value inclusion, and we do not discriminate based on race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status or disability status.