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BNV-East Lake BOS/Surgery 6300 East Lake Blvd Vancleave, MS 39565, USA Responsible for managing a group of patients throughout a ninety-day episode of care, as part of the Bundled Payment for Care Improvement (BPCI) Advanced program, Blue Cross Blue Shield Bundled patient and any other bundled programs. Completion of preoperative risk assessment and post op clinical care assessments. Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the continuum of care, including pre-operative, acute stay, Inpatient Rehab (if applicable), Skilled Nursing (if applicable), Long Term Acute Care (if applicable), Home Care (if applicable) and access to community resources (if necessary). Development and implementation of collaborative care plans throughout the continuum of care, specific to patient individual needs. Collaborate with physician and monitor all providers in the pre-operative, acute, post-acute and outpatient settings, to identify patient needs such as: home health care, DME, physical therapy and community services. Provide telephonic and/or onsite follow up with patients at planned intervals and as needed based on patient status. Complete and submit all required documentation within established guidelines. Input & maintain all files & documentation within care management system & practice medical record as appropriate. Ongoing evaluation and revision of plan of care as determined by patient's health status. Communicate changes to all providers and multi-disciplinary care team members involved in the patient's care. Identify gaps or barriers in the treatment plan and provide appropriate resources and services. Update care plan as needed throughout the continuum of care. Understand the BPCI and other Bundle programs design, implementation, management, monitoring and reporting requirements. Remain flexible and responsive when changes occur in patient activity and workload. Maintain patient confidentiality and HIPAA compliance. Perform other duties as assigned. Education: RN Preferred LPN with 10 years of experience Education and experience considered for negotiation Licensed to practice Nursing in Mississippi 2-3 years’ of Nursing experience required; orthopedic experience is highly preferred; experience in discharge planning and outpatient care coordination preferred Other Requirements: Exceptional customer service, interpersonal skills, and communication skills; Proficiency of electronic records systems preferred. Must have strong data entry skills; Must be able to complete tasks with a high-degree of efficiency and accuracy while working in a fast-paced environment with frequent disruptions; Must demonstrate ability to analyze data and resolve complex problems; Must have the ability to work independently while managing time and workload appropriately; Must be able to travel to various locations and work overtime hours as needed. Job Type: Full Time- On Site Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr