RN ACO Nurse Case Manager, Nashville and Birmingham Alabama-2

RESPONSIBILITIES: [Key position functions which support the critical success factors]


* Identify and tracks Primary Care Physician (PCP) preferences for direct patient interactions


* Make routine visits to PCP offices and facilities


* Meet with PCP's and their staff as needed, to discuss high risk patient status, discharge plans, hospitalization avoidance strategies and ensure end of life preferences are identified


* Review recent admission trends and history with PCP and staff


* Communicate directly with patients experiencing transitions in care for a prescribed length of time to determine if post discharge needs are met, follow-up appointments are made and kept, and conduct a medication reconciliation


* Act as a Health Coach, providing patient education with a goal of improving their overall health while improving the ACO quality measures


* May be assigned duties of a team lead in a specific geographic area.

Responsibilities may include, but are not limited to: staff scheduling, staff performance input, staff training and nurse-provider relationship building


* Participate in CareAllies team meetings to review and discuss ACO trends, variances, problem areas and opportunities


* Collaborate with Local Network Operations Team on a scheduled and as needed basis


* Participate in the annual quality measure abstraction as a SME


* Document all interactions and workflow management in a concise and accurate manner in Arcadia


* Make routine visits to acute in-patient facilities, post-acute care facilities


* Identify/ receive notification of MSSP patients admissions and discharges in the acute care setting


* Develop and maintain collaborative relationships with key personnel in high volume acute care facilities to coordinate with the facility discharge planner to ensure an appropriate transition of care plan is in place



* Develop and maintain collaborative relationships with key personnel in high volume post-acute care facilities to coordinate with the facility discharge planner to ensure an appropriate transition of care plan is in place


* Coordinate care in alignment with evidenced-based guidelines


* Communicate directly with patients to determine post discharge preferences, discharge needs and work with the hospital or post-acute care management staff to ensure appropriate plans are in place


* Act as a resource for the PCP and communicate admissions, discharges and discharge plans for high risk patients to the PCP, their staff and the assigned ACO Practice Coordinator

REQUIREMENTS:

Travel to the Nashville, TN area and Birmingham, AL Area

Experience/ Education:

Experience/ Education:


* Current unrestricted AL state RN license


* Baccalaureate degree preferred


* Three or more years of clinical experience in an acute care, post-acute care or community setting


* Minimum of two years of experience in Case Management or Utilization Review
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