Provides care under the direct supervision of the Director of Care Management utilizing physician approved patient protocols according to established standards and best practice guidelines. Facilitates the communication between patient/caregiver, physician and the outpatient care team to optimize health and wellness, reduce inpatient admission, reduce re-admissions and improve medical stability in the ACO patient population served. Works collaboratively with Nurse Navigators to manage medical stability in patients with high risk disease management with complex comorbid conditions.
Manages a case load of 5,000-7,500 patients with identified gaps in care in collaboration with the Health Care Team.
Works in collaboration with the PMH Team in the design, implementation and evaluation of the PMH model.
Works proactively to coordinate preventative/follow-up care for all patients receiving care from ACO participating providers.
Reviews information to see if necessary information is on hand and is accurate.
Review of patients' medical condition, including gathering pertinent data, patient information by telephone, medical histories and medication lists.
Reviews the medical records specifically for healthcare issues/problems, educational and psychosocial needs of the patient/caregiver.
Documents in Wellcentive and provider EMR (if applicable) per policy and schedules needed preventative services using evidenced based Physician approved protocols.
Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services.
Assists Nurse Navigators' in contacting discharged patients to schedule return visit with the PCP per guidelines.
Collaborates with PCP to enhance evidenced-based clinical guideline adherence and promote best practice by ordering per MD approved protocol labs and diagnostic testing.
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing.
Phone contact with patients' families, physicians, nurses and other health care personnel internal/external to the Health System in order to schedule appointments, ordering of labs and diagnostic testing per physician protocols
Works collaboratively with PCP team to continuously evaluate process, identify problems and propose process improvement strategies to enhance the PHM delivery of care model.
Utilizes educational and behavioral change strategies to promote patient involvement in self-care.
Incorporates excellent written, verbal and listening communication skills, positive relationship building skills and problem solving into patient care coordination practice.
Performs duties as required or assigned for specific operational purposes for which they are qualified to perform.
Decisions are varied, but are usually confined to situations which are familiar. Past experience or practice provides several alternative solutions to choose from
Maintains, obtains all professional CEU's in compliance with State and Regulatory requirements.
Daily contact with co-workers in the corporate office and with regional clinic staff.
Must maintain confidentiality in all areas at all times
Vocational/Technical School graduate
Basic LVN nursing skills
Knowledge of lab procedures and diagnostic testing
Ability to write clear documentation and ability to write detailed specifications.
Solid organizational skills including attention to detail and multi-tasking skills.
Basic computer skills
3 years clinical nursing experience and/or 2 years' experience in clinic setting, Population Health Management or Patient Centered Medical Home
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.