Oversee clinical care to patients with complex care needs, chronic disease and through transitions of care. Serves in an expanded nursing role to collaborate with the Medical Team to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Integrates evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Reports to: Regional Manager, Care Coordination for Beacon Health, LLC.
Manage utilization and practice metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population
Monitor patient progress and promote early intervention in acute care situations
Provide safe transition of care across the continuum of care
Provide patient education
Promote patient independence and self-management
Demonstrate autonomy being accountable for their practice
Demonstrate the ability to negotiate and influence individual and group decision- making.
Adapt to a fluid, dynamic and rapidly changing environment.
Demonstrate leadership qualities in the areas of time management, problem solving, decision making, priority setting, delegation, organization, written/verbal communication and listening skills.
Works with Beacon Health leadership in the design, implementation and evaluation of the Medical Home care model.
Implement monitoring systems for high-risk member to prevent and/or intervene early during acute exacerbations. Works with the primary care physician to ensure appropriate standing orders for acute exacerbation management (such as diuretic titration protocol).
Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population.
Provides regular progress updates to PCP and other members of the care team.
Collaborates with the Inpatient and Continuing Care Coordinators to ensure smooth process in place when movement between settings occurs.
SKILLS AND ABILITIES:
Needs to be professional as well as knowledgeable, responsible, and accountable to manage patient care over the continuum and to assist in improving quality, cost, and patient/service satisfaction outcomes.
Will be responsible for the assessment, planning and implementation process for a select group of patients in the outpatient setting.
Must be organized with the ability to self-motivate and prioritize a
variety of duties.
Proficient in computer literacy including but not limited to the electronic medical record, electronic data entry, retrieval and report generation.
machine, copier, calculator, etc.
EDUCATION AND/OR EXPERIENCE:
Registered Nurse with three to five years of recent (within the last 3 years) acute care experience or relevant experience required. Licensed at an RN level by the State of Maine Board of Nursing.
Bachelor's degree in Nursing preferred
Three to five years of recent (within the last 3 years) acute care experience or relevant experience required. Knowledge of the basic principles of care management and care coordination required. BLS Certification.
Experience in care management/care coordination to include care planning, resource management, and utilization management desired. Prior experience in Primary Care setting desired.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Eastern Maine Healthcare Systems