JOB SUMMARY Responsible for assessing the physical and psychosocial needs of patients and families and provides intervention to meet those needs utilizing personal, family, and community resources. Coordinates with clinical and social service providers across traditional and nontraditional settings including, but not limited to hospitals, primary care offices, homes, social service agencies. Coordinates with health system case managers and leads across boundaries.
Key
Essential Function Clinician: Designer/coordinator/integrator/evaluator of care to individuals, families, groups, communities, and identified populations of vulnerable populations. Demonstrates ability to understand rationale for care and competently deliver interventions to an increasingly complex and diverse population in multiple environments and settings. Performs and/or oversees the holistic assessment and develops a community based plan of care.
Carries a caseload of complex patients. Outcomes Manager: Synthesizes data and translates into information and knowledge to evaluate and achieve optimal health outcomes. Collects data on interventions and outcomes Advocacy: Adept at ensuring that patients, families, and communities are well-informed and included in planning care and is an informed leader for improving care.
Serves as an advocate for the patient and the professional and interdisciplinary team. Educator: Utilizes appropriate teaching principles and strategies as well as current information, materials and technologies to teach clients, groups and other healthcare professionals. Creates, maintains and adjust individualized care plans for patients that address both medical and social barriers to accessing care.
Works in conjunction with outreach team on intake assessments/care plan including medical needs/barrier identification of patients enrolled in the program; determine plan for care management. Promote activities related to the delivery of clinical services, including, but not limited to utilization review, quality assurance and clinical protocol development. Essential Function Plan and execute interdisciplinary case conferences/team meetings and clinical rounds.
Forge and nurture partnership with hospitals, medical offices and local service organizations to broaden support services for patients. Implements policies and procedures to ensure that patients are discharged from the hospital with appropriate support systems to prevent re-admission. Demonstrates the knowledge and skills necessary to provide care appropriate to patient population and within clinical competency.
Demonstrates knowledge of the principles of growth and development and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify the requirements of each patient, and to provide the care needed as described in departmental policies and procedures. Works collaboratively with hospital staff and other community/human services agencies to coordinate intervention activities; ensures that patients receive efficient services for problem resolution.
Utilizes computer and information systems to enter, format data and generates statistics, computations, tables, charts and graphs. Maintains confidentiality of information in accordance with HIPAA/compliance policies and procedures. Completes required continuous training and education, including department specific requirements to maintain knowledge of case management and utilization review practices.
Responds to problems/opportunities to improve work environment and participates in unit based performance improvement activities. Attends in-services, educational programs, conferences and other meetings as required. Supports and is involved in the organization’s Performance Improvement initiatives.
Coordinates and integrates activities within complex care and other departments to maximize overall effectiveness of the department. Physical Demands A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Physical Demand N/A Rarely Occasionally Frequently Constantly Weight Standing X Walking X Sitting X Lifting X Carrying X Pushing X Pulling X Qualifications Education Education Level Education Details Required/ Preferred Bachelor's Degree in Nursing Required and Master's Degree in Nursing or Public Health Preferred and Education, training or experience to work with the patient population as assignment dictates. Required Work Experience Experience Experience Details Required/ Preferred Minimum 3 years experience Acute care nursing experience.
Required and Progressive experience in health care including direct patient care, educating staff and patients, problem solving at unit and organizational level. Project management experience or evidence of skills and abilities which demonstrate project management skills. Significant experience in continuous quality improvement and project management of an interdisciplinary team.
Required and Experience in designing an approach, determining resources needed to complete the project, selection of methodology, process evaluation and completion of work. Required
Any