Value Based Care (VBC) Nursing Care Manager

The responsibilities of this job include, but are not limited to, the following:

• Assisting the VBC Director by coordinating and managing of the day-to-day operation of Patient First's telephonic care management program including, but not limited to: schedule creation and management, fielding of department concerns, workflow troubleshooting, monitoring department performance/efficiency, and conducting regular department meetings;
• Assisting the QIC Project Director in maintaining excellent clinical standards for all Nurse Care Managers that are aligned with Patient First's quality expectations;
• Ensuring that Patient First satisfies all current clinical contractual obligations related to the care management program;
• Assisting in the clinical review and assessment of future program opportunities, including participation in both internal and external multi-disciplinary meetings as needed;
• Serving as a telephonic care management resource to clinical teams, including:
• Developing and maintaining strong relationships with Patient First physicians to integrate the care management program into their practices;
• Working with IT resources to facilitate onsite registry reporting and documentation of evidence-Based Care (EBC) in searchable fields;
• Working with the VBC Director, clinical leadership, and the QIC Project Director to define quality measures, establish goals, and develop protocols and point of care reminders using nationally recognized EBC measures;
• Working with VBC Director, clinical leadership, and the QIC Project Director to improve the effectiveness and efficiencies of clinical practices and processes;
• Reviewing patient medical records and both internal and external reports to identify and research possible gaps in care;
• Working with clinical leadership to identify strategies to address and close identified gaps in care at the practice level;
• Using the resources available, actively and efficiently identifying patients appropriate for care management;
• Maximize the patients' health, wellness, safety, and self-care through quality care management, patient satisfaction, and cost-efficiency;
• Assisting center nurses and other members of the healthcare team by providing advice and handling emergent or urgent calls that are within the Nurse Care Manager's scope of professional practice;
• Actively managing assigned panel of chronic care patients telephonically, including:
• Developing relationships with patients as an integral member of the healthcare team;
• Assessing patients' physical and psychosocial needs, to include establishing literacy status and deficits of the patient, family, and caregivers;
• Educating patients and healthcare team members on the importance of care coordination and preventive care;
• Supporting efforts to help ensure that a complete health assessment is performed and on file for each identified primary care patient to meet individual payer contractual requirements;
• Working with patients and the patients' care team to coordinate change readiness and needs assessment, and developing individualized treatment care plans;
• Monitoring and evaluating effectiveness of the treatment care plan and modifying as necessary;
• Providing expert clinical guidance resulting in transformational changes in the patients' overall well-being;
• Assisting patients in setting specific, measurable, achievable, relevant, and time-based (SMART) goals for self-management;
• Teaching patients how to conduct self-management tasks and reporting abnormal findings to the care team;
• Promoting patient engagement and self-management by involving the patient in activities to improve his or her health;
• Consistently documenting patient self-management measures, availability of a mutually agreed upon care plan, and reporting of progress towards identified goals;
• Collaborating with patients, family members, caregivers, physician, and other care team members to assess the patients' progress toward identified health care goals;
• Managing various aspects of the patients' care (e.g., referrals to specialists, hospitalizations, emergency room (ER) visits, ancillary testing, and medication reconciliation) and assisting the patient in coordination of care;
• Communicating with patients to ensure compliance with recommendations and follow-up visits;
• Reviewing documentation from other providers (e.g., hospital discharge summaries), following up with the patient as necessary, and documenting conversations with and recommendations made to the patient in the electronic medical record as appropriate;
• Providing telephone advice per Patient First protocols and handling urgent and emergent calls;
• Anticipating the needs of the chronic care patient population and ensuring that necessary documentation and pre-visit planning is completed or requested prior to the patient's visit;
• Instructing and encouraging patients on use of the Patient First patient portal;
• Facilitating communication between members of the healthcare team and patients in the decision-making process;
• Assessing patient barriers to complete treatment goals through the use of motivational interviewing and assisting the patient in mitigating issues and removing barriers to care;
• Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams;
• Collaborating with payer case/chronic disease managers for additional services as appropriate;
• Developing a list of medical supply and community resources available to patients, and maintaining collegial relationships with frequently used organizations;
• Working with consulting physicians, hospitals, ERs, and other frequently used health care resources to clarify roles and develop effective and efficient communication;
• Facilitating, advocating, and intervening on behalf of the patient to ensure successful implementation of the treatment care plan and continuity of care.

• Eighteen years of age or older;
• RN, BSN preferred;
• Ability to be licensed in all states in which Patient First operates;
• Minimum of three years clinical experience in Medical/Surgical, ER, Critical Care, and Ambulatory Care preferred;
• Experience or certification as a Case Manager, Care Manager or Clinical Navigator. Experience in Primary Care/Patient Centered Medical Home or equivalent environment that coordinates care across multiple providers/care settings preferred;
• Telephonic triage, coaching, or care coordination experience required;
• Ability to work in a team-oriented environment, highly organized and well-developed strong oral, written, and interpersonal communication skills;
• Demonstrates sound judgment, decision making, problem solving, and analytical skills;
• Strong professional level of knowledge of comprehensive clinical assessment in the adult population and chronic disease management;
• Knowledge of psychosocial aspects of chronic illness;
• Experience in quality improvement, quality and efficiency metrics, and data analytics preferred;
• Demonstrated success in influencing patients and providers;
• Experience with medically oriented care plan documentation;
• Ability to develop and implement plan of care;
• Self-disciplined, self-directed, motivated, energetic, passionate, and innovative;
• Exceptional oral, written, and presentation skills;
• Skilled in active listening, critical thinking, social perceptiveness, active learning and instructing methods for patient engagement and activation;
• Comfortable managing multiple-tasks and continually re-prioritizing;
• Must have the ability to delegate and make sound judgment while working with employees and providing medical care;
• Ability to work effectively with all levels of administrative and professional personnel;
• Able to maintain confidentiality with all aspects of information in accordance with the organization and HIPAA;
• Proficient computer skills to include word processing, spreadsheet, presentation preparation, and database management;
• Must be able to hear pages, bells, and phone system;
• Must be able to sit, stand, and walk for long periods of time (possibly 4-7hours at a time):
• Must be able to lift moderate to heavy items (20-50 lbs.);
• Ability to travel, including overnight, to attend meetings, conferences, etc. as needed;
• Maintain current CPR, ACLS, and PALS certifications.