ACO RN Case Manager/Beneficiary Care Navigator

Hours of Work :

8:00 AM- 5:30 PM

Days Of Week : M-F Work Shift : Job Description Your Job: The Beneficiary Care Navigators carry a caseload taken from a population of individuals whose disease acuity has been determined to be moderate to severe, using a stratification process that incorporates data from available encounters, claims, lab, medication, and admission databases. You will work closely with clinical support staff, nursing leadership, physicians, quality department, and the information technology department, the Beneficiary Care Navigator is tasked with achieving system goals of improving clinical outcome for patients with chronic diseases by using timely and appropriate coordination of quality healthcare services to meet an individual’s specific health needs to promote positive outcomes. Supports the mission, vision, values and strategic goals of Methodist Health System. Job Requirements Bachelor of Science in Nursing preferred or equivalent professional experience in provision of Primary Care with this population is highly desirable. Excellent communication and interpersonal skills. Good oral, written and presentation skills. Bilingual (English/Spanish) a plus. Advanced Cardio Life Support Certification preferred. Current Basic Life Support Certification required Current license to practice professional nursing in the state of Texas required. Job Responsibilities Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments. Assist patients in setting SMART goals for self –management, teaching them how to do self-management tasks and report abnormal findings to their physician team. Collaborate with payer Case Managers for additional services when appropriate. Collaborate with physicians, providers, and practice staff in identifying appropriate patients for care management. Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals. Consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals. Develop a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently. Overseen the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams. Promote patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Provide follow-up contact with patient as indicated to ensure compliance with recommendations — medications, lab/x‑ray, specialist visits, PCP visits, dietitians, CDE, etc. Responsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls. Utilize the Institute for Healthcare Improvement (IHIs) Chronic Care Model as foundation and framework for chronic illness care management. Other job duties as assigned. #J-18808-Ljbffr Dormont Manufacturing Co