Job Purpose: Work under the direction of the Care Manager, RN, to establish, implement, monitor, and evaluate high quality, cost-effective care plans as patients move across the care continuum for a designed population.

Essential Duties and Responsibilities

Review of the patient's health status, medical and social, utilizing data from the electronic medical record claims, and additional resources shared with community providers
Outreach to patients to confirm diagnosis, contributing factors, anticipated treatment plan, current and projected functional ability, and barriers to care
Act as an extension of the primary care practice by partnering and collaborating with interdisciplinary team members across the continuum of care
Facilitate access to necessary care by navigating barriers and advocating for the patient; educate patients and families/caregivers on the plan of care, the barriers to that care, and set expectations while setting achievable, safe goals
Review patients enrolled in care management each month to ensure treatment goals are met and the care plan is shared across the care teams, utilizing care coordinators as necessary
Integrates the primary care team and Specialty Services (i.e. nutrition, behavioral health, medication therapy management), as applicable to support the achievement of health outcome goals with continuity of care
Evaluate, coordinate, manage, and document all activities related to care management and ensure tracking of resource utilization and time is accurate
Identify patients who are at risk for high utilization and determine possible supportive services, programs, or additional caregivers that could assist in reducing this risk and coordinate needed referrals or outreach, utilizing the referral department and care coordinators as necessary, to provide access to these additional supportive services
Complete all required documentation in the electronic medical record; making team members aware/collaborating throughout the continuum of care
Communicate regularly with integrated team members
Track patients who have had a recent ER visit, hospital admission, or inpatient procedure and reach out to provide support, maintain continuity of care between hospital and PCP, and reduce risk for readmission
Assist with primary care provider triage assessment and direct patient to appropriate services
Track patients throughout their care plan and perform a warm handoff to the appropriate next provider to care in the interval between primary care visits and care plan updates
Demonstrate initiative and creativity by identifying modifications in processes and workflows that will improve our ability to deliver cost effective, high quality care
Assume accountability for professional growth and development, including a working knowledge of regulations/initiatives, trends in ambulatory and cross continuum care management, and accountable care organizations
Utilize information technology systems to identify high risk patients, contributing factors of risk and gaps in preventative and chronic care management
Develop and maintain a sound working relationship with internal and external stakeholders
Collect data as needed within initiatives for ongoing analysis

Additional Duties and Responsibilities

Accomplishes all tasks as assigned or become necessary

Qualifications
Education, Experience and Licensure:

Holds one of the following:

Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Certified Medical Assistant (CMA, CCMA, RMA)
Certified Nursing Assistant (CNA)

Case management experience, preferred
Bachelor's degree in healthcare of life-science related field, preferred
At least 1-3 years of healthcare experience with direct patient care
Experience with home health nursing, health coaching/education, medication administration, and/or care for geriatric populations, preferred

Knowledge, Skills, and Abilities:

Medical, administrative, and/or Customer Service experience
Strong written and verbal communication
Knowledge of common medical terminology
Patient confidentiality, HIPAA
Team player
Strong computer skills
Detail-oriented
Strong time management and workload prioritization
Extensive pharmacological knowledge

Language Skills:

Ability to communicate well in writing and in person. Ability to read and interpret common medical
terminology.

Expectation of Employee

Adheres to Avance Care's Policy and Procedures
Work as a team player
Performs administrative duties as workload necessitates
Maintains company confidentiality in all areas
Maintains a positive, respectful attitude, high team spirit and morale
Uses tact in all personal interactions
Remains congenial and enthusiastic to please patients
Consistently reports to work on time for scheduled shift, prepared to perform duties of position