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Form of workSIGN-ON BONUS AVAILABLE!!
**Monday through Friday Schedule**
JOB PURPOSE:
Responsible for the oversight of clinical care management and care oversight of an identified caseload of PruittHealth Premier Plan members that reside in long term care facilities and are enrolled in the PruittHealth Premier I-SNP. Works In collaboration and consultation with the Plan Provider, staff RN's and other health care professionals and provides care coordination and care management activities on behalf of the PruittHealth Premier Plan. Collaborates with the Plan Nurse Practitioner/PA to assist in managing the member's care needs, preventing acute and chronic illness and disease, and promoting wellness. Assist patients to achieve optimal health status utilizing the most cost-effective quality resources through application of model of care practice guidelines. Implement appropriate interventions to manage multiple physical, psychological, social and financial barriers in cooperation with the patient, PruittHealth Premier, and medical provider.
KEY RESPONSIBILITIES:
Duties may include, but not limited to the following:
Complete comprehensive, adult/geriatric assessment as required for patient change in condition assessment to report findings to the Plan Provider timely to allow them to provide changes to the plan of care/implement new orders.
Identify and document the needs of clinically complex patients including high acuity and skilled patients.
Follow up on medium acuity patients as directed by the Plan Provider.
Check in daily with each assigned facility (each nursing station) to determine members needing more urgent visits.
Assist with IV insertions, lab draws, and wound care as ordered by the Plan Provider
Responsible for coordination with facility staff for scheduling and completion of the inter-disciplinary team meeting quarterly with the Plan Provider and Interdisciplinary Care Team.
Coordinate care as member's transition through different levels of care and care settings, ensures that the ICP is communicated immediately and/or no later than 1 business day to the receiving care setting
Coordinate with utilization management and hospital case management as needed for member transitions to and from and acute setting.
Assists with Health Risk Assessment within seven (7) days of enrollment for a new beneficiary and annually within one year of the initial assessment. Completes the record review and validates and updates the HRA for Plan Provider to review when doing their comprehensive exam.
Ensures all Members have an ICP developed within 2 business days of HRAT by Plan Provider
Facilitates agreement and implementation of the member's plan of care by engaging beneficiary, the facility staff, families/responsible parties, primary and specialty care physicians
Collaborate with Plan Provider (NP/PA), case managers, social workers, family members, key care givers and any appropriate ancillary medical personnel as appropriate
Ability to effectively reconcile medications
Understand the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decision-makers
Ensure members have access to supplemental benefits and ancillary service providers as clinically needed or annually for wellness related benefits.
Provide care management and coordination to assure that the patient progresses through the continuum of care and utilizes the most clinically appropriate and cost- effective quality resources through the application of national practice guidelines.
Conduct care coordination for any member discharged from a PruittHealth facility with facility staff, patients and caregivers to ensure access to appropriate care resources based on their setting of care in a timely manner.
Monitor the needs of patients and families on an ongoing basis while facilitating any adjustments to the plan of care as changes are needed.
Helps to assure that the patient has access to primary care provider (PCP) and specialists, supplemental benefit services and is understanding of treatment plan and medications and assists with coordination of transition between care settings.
Function as an effective liaison between patient, PruittHealth Premier Plan Provider, facility staff, and other community health providers to ensure appropriate clinical oversight and engagement is provided
Reviews and interprets the medical and social history of members
Reviews laboratory data to escalate concerns timely to Plan Provider and recommend appropriate follow-up
Ensures that individual plan of care is developed with specific interventions designed to meet the needs identified in the Health Risk Assessment
Attend morning facility meetings on days they are scheduled to be in that facility.
Attend monthly QAPI meeting if Plan Provider is unable to attend.
Responsible for identifying overall quality improvement activities
Performs other duties as assigned
KNOWLEDGE, SKILLS, ABILITIES:
Proven ability to perform comprehensive, adult/geriatric assessment
Demonstrates ability to identify and document chronic disease in adults
Demonstrates ability to recognize conditions, characteristics, and behaviors that place seniors at risk
Proven ability to pursue feedback, continuing education and professional development
Ability to interact with a wide variety of people and handle complex situations simultaneously with customer service focus
Performs comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
Adhere to PruittHealth Premier goals, objectives, standards of performance, and policies and procedures.
Ensure compliance with quality patient care and regulatory compliance within the company's standards and RN scope of practice.
Comply with PruittHealth Premier's confidentiality policy, HIPAA requirements and state and federal regulations.
Attention to detail and follow-up and the ability to analyze and problem-solve
Experience with electronic clinical charting/records
Manage assigned case load as business needs dictate.
Excellent time management, flexibility, and efficient organizational skills with ability to work independently and as a team player in both office/remote environment
Adherence to legal and ethical principles of privacy, confidentiality, safety, advocacy, and accreditation and regulatory standards in all case management activities in both office/remote environment
Ability to work in triage and/or disease management role if needed
Compliance to internal and external goals/metrics established for assigned department
Position is often required to independently plan and prioritize patient care objectives.
Rotating on call responsibilities possible
Travels between care sites required
TECHNICAL SKILLS
Proficient computer skills in Windows, Care Management Platforms, and general Internet use.
Ability to chart and follow designated workflow(s) in an electronic environment.
Proficient in typing
COMMUNICATION SKILLS
Strong verbal and written communication skills required 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
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 experience in utilization review/case management and at least two years case management, home care or hospice experience strongly preferred.
Two years' experience with long-term care population preferred
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Licensed Registered Nurse with current, unrestricted license in state of practice required.
Certified Case Manager preferred
Current CPR certification
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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.
