Ambulatory Complex Coordinator Registered Nurse

apartment TriHealth location_onCincinnati, OH, US

Job Overview

JOB DESCRIPTION

The goal of Ambulatory Complex Care Management is to help patients reduce ED and inpatient admissions and avoid re-admissions through longitudinal care management interventions that increase patient self-management activities of chronic diseases thereby improving quality of life. The Ambulatory Complex Care Manager supports the TriHealth Primary Care Physician practices utilizing clinical nursing skills to provide care management and make transition of care calls to value based patients discharged from inpatient and emergency hospital settings.

Job Requirements

Associate's degree or diploma in Nursing

RN, Registered Nurse

Progressive experience as a RN in a hospital, ambulatory or home health setting

Care Management Experience Is Preferred

Strong oral and written communication skills as well as strong customer service skills with phone etiquette Collaborates well with the interdisciplinary team Proficient computer skills

Epic Experience Is Strongly Preferred

2-3 years experience Clinical Nursing Hospital nursing

2-3 years experience Clinical Nursing Care Management, Home Care

Job Responsibilities

Maintains their panel of patients , completing assigned outreaches at the intervals they are due, and manages using evidence-based care such as Standards of Practice for Case Management, NCQA Standards for Care Management and program description. Utilizes both clinical and claims reports, discharge reports, predictive modeling reports to identify patients that would benefit from enrollment into the programs.

Ensures enrolled patients have a documented attempt for advanced care planning discussion, and this is documented in the EMR. Appropriate resources are sent to the patients and consults are made for assistance with ACP as needed. RN Care Managers provide education to patients and their families on the importance of ACP and encourage them to complete these documents and provide copies for the EMR. The Care Manager has attended MOLST training.

Collaborates with the interdisciplinary team and Primary Care Providers consistently and professionally. Communicates with their enrolled patients on a consistent bases and this is documented in the EMR in a standard way utilizing smart phrases.

TOC: Enrolls a large population of targeted patients with specific insurance contracts into the TOC program, makes scheduled outreach calls and schedules PCP follow-up appointments for these patients within specified timeframe thereby reducing re-admissions. Refers patients to CCM on a consistent basis. CCM: Enrolls patients, creates care plans, makes monthly follow-up calls and dis-enrolls patients once patients meet goals and/or before target date. Follows NCQA guidelines, policies and procedures, and program description. RN's make appropriate referrals and document using standardized smart phrases.

Completes all department assigned and mandatory education and attends at least 75% of the monthly department meetings. Attends daily huddles, has their camera on when required, is available and active on web ex and e-mail throughout the working day, is responsive to calendar invitations and attends scheduled meetings on their calendar on a consistent basis.

Other Job-Related Information

Working Conditions:

Climbing - Occasionally

Concentrating - Frequently

Continuous Learning - Frequently

Hearing: Conversation - Consistently

Hearing: Other Sounds - Consistently

Interpersonal Communication - Consistently

Kneeling - Rarely

Lifting <10 Lbs - Occasionally

Lifting 50+ Lbs - Rarely

Lifting 11-50 Lbs - Rarely

Pulling - Occasionally

Pushing - Occasionally

Reaching - Occasionally

Reading - Frequently

Sitting - Frequently

Standing - Occasionally

Stooping - Rarely

Talking - Consistently

Thinking/Reasoning - Frequently

Use of Hands - Frequently

Color Vision - Frequently

Visual Acuity: Far - Occasionally

Visual Acuity: Near - Consistently

Walking - Occasionally

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, We Believe There Is No Responsibility More Important Than To SERVE Our Patients, Our Communities, And Our Fellow Team Members. To Achieve Our Vision And Mission, ALL TriHealth Team Members Are Expected To Demonstrate And Live The Following

Serve: ALWAYS…

Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS…

Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
Offer patients and guests priority when waiting (lines, elevators)
Work on improving quality, safety, and service

Respect: ALWAYS…

Respect cultural and spiritual differences and honor individual preferences.
Respect everyone’s opinion and contribution, regardless of title/role.
Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS…

Value the time of others by striving to be on time, prepared and actively participating.
Pick up trash, ensuring the physical environment is clean and safe.
Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS…

Acknowledge wins and frequently thank team members and others for contributions.
Show courtesy and compassion with customers, team members and the community

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