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Ambulatory Case Manager RN - UHC Specialty Care Clinic - Full Time

Company: Lafayette General Health
Location: Lafayette
Posted on: May 14, 2019

Job Description:

SUMMARY: The RN Ambulatory Care Manager (ACM) is a practice-based RN who directly supports ambulatory clinics high-risk and/or vulnerable populations. In collaboration with other members of the Ambulatory team, the ACM is responsible for organizing, coordinating, and providing care coordination and care management services to patients within the physician practices who are most at risk for health deterioration, hospital readmissions, and/or poor outcomes. Improves overall outcomes by identifying care gaps within key Healthe registries and disease categories. ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Proactively supports Patient Centered Medical Home and Healthe Registry initiatives related to Care Coordination. 2. Coordinates and implements meaningful clinical process of care and outcome measurement systems in conjunction with service lines and all LGH entities. 3. Participates in team meetings and quality improvement initiatives. 4. Coordinates continuity of patient care with external healthcare organizations and facilities. 5. Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ED visits by incorporating evidence-based practices and procedures to achieve patient centered care across the care continuum. 6. Provides periodic updates to leaders about the clinical population and areas to target for improvement. 7. Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a Healthe Registry. 8. Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient caf? plans. 9. Facilitates patient medication management based upon standing orders and protocols. 10. Participates on team for data collection, health outcomes reporting, clinical audits, and PCMH initiatives. 11. Participates in testing and piloting of performance improvement solutions. 12. Manages assigned patient registries by identifying care gaps that exist within defined high-risk populations. 13. Coordinates patient interaction with all team members, including office staff, Chronic Care Management navigators (CCM), and/or hospital case management. 14. Coordinates care gap action plans with patients to include scheduling office visits with providers, communicating necessary testing and follow-up with office prior to patient visit, aligning patient with available community and health system resources for outcome improvement, corresponding with insurance care coordinators/navigators, and educating patient/family of resources in effort to avoid hospital readmission and/or unnecessary ED utilization. 15. Utilizes Healthe Registries to develop tracking system for patient care coordination and care management across the continuum, including care transitions between hospital and ambulatory setting, and/or primary and specialty care. 16. Communicates with referring physicians' offices and interdisciplinary team as appropriate to the patient and provider's needs. 17. Performs other auditing, data collection, and other related duties under the direction of the LGMD Vice President. 18. Insures Health Insurance Portability and Accountability Act is adhered. EDUCATION/TRAINING/EXPERIENCE: 1. RN license with two to three years of experience with general knowledge of physician office operations and regulatory requirements. 2. Case management, disease management, home health care nursing, and/or outpatient education preferred. 3. Demonstrated ability to work effectively with physicians, patients and other medical professionals. 4. Must possess communication skills necessary to interface with physicians, employees, patients, and general public in a tactful, confidential and diplomatic manner. 5. Must have problem solving skills, creativity, initiative, and analytical ability. 6. Must have skills in comprehensive nursing assessment; care plan development; relationship building with patients, staff and providers; documentation in EMR; computer skills including Excel and Word. 7. Ability to manage multiple projects and activities on a routine basis, with minimal supervision. 8. Demonstrated knowledge of continuous quality improvement techniques. 9. Working knowledge of major quality improvement efforts (PQRS, NCQA, and HEDIS.). EQUIPMENT OPERATED: * Computer * Various PHYSICAL DEMANDS AND WORKING CONDITIONS: * Medium Work as defined by the U.S. Department of Labor constitutes a maximum lift of 21-50 pounds on occasion and/or a maximum lift of 11-25 pounds on a frequent basis * May be required to assist in the turning, lifting, or moving patients as well as walking about from patients' rooms, as well as to and from various hospital areasSDL2017

Keywords: Lafayette General Health, Lafayette , Ambulatory Case Manager RN - UHC Specialty Care Clinic - Full Time, Executive , Lafayette, Louisiana

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