- Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, members legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services. Coordinates care of individual clients with application to identified populations using assessment, care planning, implementations, coordination, monitoring and evaluation for cost effective and quality outcomes How you grow, learn and thrive matters here.
- Educational and career development options, including tuition and certification reimbursement, scholarship opportunities
- Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern)
- Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions)
- Malpractice liability insurance
- Loan forgiveness through the New Mexico Higher Education Department
- EPIC electronic charting system Type of Opportunity: Full time FTE: 0.90 Job Exempt: No Work
Weekday Schedule Monday-Friday
Supports patients in a hospital and inpatient or clinic setting Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, member s legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services.
Provides care coordination to members with chronic condition with less complex needs including less community resources. Conducts in depth health risk assessment and/or comprehensive needs assessment which include but not limited to psycho-social, physical, medical, behavioral, environmental, and financial parameters. Develops and communicates plan for authorization of services, and serves as point of contact to ensure services are rendered appropriately, i.e. during transition to home care, back up plans, community based services.
Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes; collects clinical path variance data that indicates potential areas for improvement of case and services provided; works with members and the interdisciplinary care plan team to adjust plan of care, when necessary. Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes.
Develops, documents and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs. Acts as an advocate for member s care needs by identifying and addressing gaps in care. Performs ongoing monitoring of the plan of care to evaluate effectiveness.
Measures the effectiveness of interventions as identified in the members care plan. Provides assistance to members with questions and concerns regarding care, providers or delivery system. Conducts face to face home visits, as required.
Educates providers, support staff, members and families regarding care coordination role and health strategies with a focus on member-focused approach to care. Facilitates a team approach to the coordination and cost effective delivery to quality care and services. Maintains professional relationship with external stakeholders, such as inpatient, outpatient and community resources.
Promotes the appropriate use of clinical and financial resources in order to improve the quality of care and member satisfaction. Generates reports in accordance with care coordination goals. Participates in Interdisciplinary Care Team ICPT meetings.
Assists with orientation and mentoring of new team members as appropriate. Performs other functions as required
Associates Degree in Nursing, 3 years of additional experience can be substituted in lieu of an Associates Degree. Bachelors Degree and 1 years of experience preferred. 3 years of related experience. CCM-Certified Case Manager We're all about well-being, starting with yours.
Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more. Learn more about our employee benefits. About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve.
We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. Compensation Disclaimer The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.
We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services