· Serves as the primary person to provide community-based support services and care gap closure to all Amerihealth Caritas Health Plan (ACHP) patients and follow up on results.
· Identifies members with care gaps through the use of the gaps in care lists from Navinet and the Quality Enhancement Dashboard.
· Provides education on chronic conditions, assistance, or referrals as needed.
· Provides Diabetes Self-Management Education (DSME).
· Assists with care coordination (i.e., medical/dental appointments, labs/radiology, DME, D/C).
· Serves as a liaison between BCHC ACHP patients and primary care team.
· Coordinates with each new and existing ACHP patient to establish and maintain relationships.
· Ensures continuity of care through ongoing communication with the entire team, ACHP patients and caregivers if appropriate.
· Collaborates with the ACHP patients/families to assist with individualized care planning, including preventative care and screening.
· Assesses and addresses barriers when ACHP patients have not met treatment goals via whatever method serves the patient best; written, oral and in appropriate language.
· Develops, implements and documents tracking activities associated with Patient Centered Medical Home (PCMH).
· In conjunction with other care team members, tracks all screening needs and gaps in care that create a barrier to overall quality of health.
· Follows up on referrals and all other high priority issues identified by the PCP.
· In conjunction with the Primary Care Provider (PCP) actively promotes patient and family engagement.
· Respects the centrality of the patients/families as core members of the health care team.
· Examines how the safety, quality and cost effectiveness of health care can be improved through the active involvement of ACHP patients and families.
· Examines common barriers to active involvement of ACHP patients in their own health care processes and assists to reduce barriers, when possible, through the use of the entire care team
· Utilizes strategies to empower ACHP patients or families in all aspects of the health care process.
· Develops and implements strategies to collaborate with ACHP patients, providers, families, and caregivers to enhance continuity of care and effective utilization of health care resources.
· Defines and maintains coordinated care strategies between BCHC and other inpatient and outpatient health care providers aimed at improving patient health.
· Assists with referral coordination and medication reconciliation.
· Identifies appropriate resources within BCHC and the community to support patient self-management.
· Develops and documents self-management plans and goals related to screening measures.
· Encourages participation in BCHC-based education and support programs.
· Refers patient to community-based support and education programs, community resources, behavioral health, and drug and alcohol treatment as appropriate.
· Participates in Morning Huddles at times, providing direction and assistance to other members of the Clinical Support Team as needed to improve efficiency and productivity of the meetings.
· Coordinates with community resources to provide patient education, outreach, and preventative health programs.
· Develops and provides patient education.
· Acquires pertinent patient history from the ACHP patient and/or significant interim items prior to patient appointments.
· Completes and documents all interventions and outcomes.
· Enters all necessary documentation, ensuring accuracy and completeness, required for billing, quality, and safety initiatives.
· Submits reports on a monthly basis to ACHP regarding key data points.
· Other responsibilities that become incorporated into the BCHC/ACHP RN Model.
· Participates in activities aimed at increasing the visibility of BCHC in community-wide health care initiatives.
Knowledge, Skills and Abilities
Education and Requirements
- Graduate of an accredited RN program
- Active Pennsylvania Nursing License
- BLS certification
- Certified Diabetic Educator Preferred
- Bilingual skills (Spanish) preferred
Key Competencies
- Demonstrable knowledge base to successfully function within the position.
- Ability to utilize EMR and Practice Management system.
- Proficient with Microsoft Office products (Word, Excel, PowerPoint) and Microsoft Outlook.
- Ability to prioritize, multitask, meet deadlines in a fast-paced, high-volume setting.
- Actively embraces change and identifies strategies to help self and others function well amidst change.
- Exceptional team building skills, including conflict resolution capabilities, shared decision making, and transparency in communication.
- Flexible to meet changing departmental needs.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Paid time off
- Vision insurance
Standard shift:
- Day shift
Weekly schedule:
- Monday to Friday
Education:
- Associate (Preferred)
Experience:
- Nursing: 1 year (Required)
License/Certification:
- BLS Certification (Required)
- RN (Required)
Work Location: In person