Description
Looking to use your nursing skills in more of an administrative capacity with full time hours, M-F, days in a healthcare system that makes the patients and YOU the #1 priority? Thompson Health is the place for you!
Main Function:
- Work in conjunction with a care team to identify and proactively manage the care needs of high risk patients within the primary care practice setting
- Provides assessment, care coordination, advocacy and coaching for identified patients that are at risk for hospital admissions or emergency room visits.
- Uses established Finger Lakes Health System Agency (FLHSA) CMMI grant criteria to identify at-risk patients
- Determines the drivers of risk in conjunction with the patient, family, physician and ancillary health care providers
- Measures the impact of care coordination interventions, and regularly re-assesses the patient's risk for incurring adverse health outcomes
Required Job Specific Competencies:
- Ability to develop and support a practice based care management model by providing on-site and telephonic services i.e. wellness, health coaching, self-management techniques, disease management and case management including coordination with community services per FLHSA standards
- Identifies high risk patients needing care management services
- Provides education, support and outreach to patients over the phone and in person ensuring all aspects of FLHSA programs are met for family practices
- Interacts closely with clinical teams to identify care gaps and improve clinical outcomes for patients with chronic conditions such as diabetes
- Active support for Thompson Practices quality programs, including PCMH and Diabetes Recognition Program
- Scans the medical literature routinely for updates on clinical practice guidelines, new developments in the management of chronic diseases and communicates and disseminates information to staff
- Complies with all required Joint Commission, state and federal regulations
Qualifications: (Licenses, Certifications)
- Current New York State Registered Nurse license required
- BLS certification
- Proficient in the use of Electronic Medical Records (EMR);
- Ability to create reports on own and interface with EMR vendor to develop reports where none currently exist
- Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint)
- Effective oral and written communication skills
- Patient Centered Medical Home and Diabetes Recognition Program knowledge and experience a plus
Experience:
- Preferred Experience: 3- 5 years of clinical nursing or social work experience, preferably with 3-5 years of community health experience, with the adult population
- Electronic Medical Record experience required
- Experience with database entry and reporting preferred
- Care Management experience preferred
Education:
- Valid NY state nursing license
- A graduate of an approved school of nursing
- BSN required
Position Pay Range: $70,000-88,000 per year
Starting Pay: Based on experience
Thompson Health is an EOE encouraging women, minorities, individuals with disabilities and veterans to apply
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