RN / RN Case Manager, Gallatin, Tennessee

Job Summary

One of the things that makes healthcare great is the relationship between a patient and their provider.  At Ascension Care Management, we are pleased to support this relationship through partnerships between our network providers, Ascension’s St. Thomas Medical Partners, and specialized Ascension Care Management care team members.  This is new and exciting work, driven by the transition to valued based care, and rooted in the desire for all patients to have high quality care with better outcomes at a lower cost.  We are seeking healthcare professionals, we call Care Coordinators, which are able to think differently about how to interact with and support both providers and patients in an office setting.  Our Care Coordinators coach, educate, navigate and break down barriers for our patients, all while using their clinical expertise to make the most meaningful impacts. If you are looking for an environment where learning is key, questions are encouraged, change is embraced, and patients come first then consider joining our growing company. Ascension Care Management… the way healthcare should be.

RN Care Coordinator Overview:

    • Access and Continuity
      • Working directly in the St. Thomas Medical Partners primary care office setting.
    • Assist with scheduling appointments as clinical needs arise
    • Maintain clear care management documentation in the office EHR
    • Performs other duties as assigned, scheduling tests and appointments, providing instruction for testing and procedures, calling in prescriptions and providing referrals.
    • Responsibilities may vary over time. Required to perform other duties as required for the efficiency and effectiveness of the department and job role.
    • Care Management
      • Evaluate and assist with risk stratification process through the use of the standard AAFP tool
      • Develop, execute and coordinate patient’s plan of care, with an emphasis on the most complicated cases.
    • Coordinate review of AAFP stratification with providers
    • Maintain regular contact with patients as defined by standard workflows, protocols, and care paths.
    • Assist in identifying patients that need services outside of the providers office, coordinate initiation of services, and regularly update provider
      • Identify patients and episodes (such as care transitions) that would most benefit from care coordination based on program objectives and patients’ risk.
    • Reconcile and coordinate medications through use of the provider EHR.
    • Comprehensiveness and Coordination
      • Ensure regular coordination and communication between all members of a patient’s health care team through interdisciplinary healthcare team meetings at least weekly in order to develop comprehensive care plans and health goals for patients
      • Work with patient to set specific health goals and track progress.  Document goals and progress in the provider’s EHR.
      • Communicate goals and patient status to partners of the patient’s healthcare team, often acting as patient advocate.
      • Provide care coordination of plan of care, including patient’s additional care needs.
      • Regularly assess caregivers needs and involve caregiver in the care planning process
      • Developing and executing patients’ plan of care including appropriate protocols and care paths for all level of clinical complexity.
    • Patient and Care giver engagement
      • Promote collaborative self-management by using techniques such as:
        • Teach back
        • Action Planning
        • Motivational Interviewing
        • Providing self-management materials for education
      • Assess levels of satisfaction of patient’s and caregivers during in person visits and other forms of communication
    • Planned Care and Population Health
      • Pre-plan with providers and other care team patients prior to a patient’s appointment
      • Use appropriate IT platforms to communicate and store information and evaluate outcomes.
    • Use data and risk stratification to identify patients with higher needs
    • Regularly meet with office care team to review metrics for populations of patients using qualitative and population data to design processes and programs that support the patients being served
    • Identify opportunities for and provision of elements of health maintenance and population management including wellness and activation objectives for both the population and individual patient.

RN Health Partner Qualifications:

  • RN (Associates or Bachelors) required.
  • Minimum 2 years’ experience in health related field required; preference in an acute care, ambulatory, or home care setting.
  • Certified Health Coach preferred.
  • Exceptional interpersonal skills with a history of working with both customers and physicians.
  • Resourcefulness and innovation to design meaningful member activities.
  • Comfort working with (and applying) web-based applications and clinical data.

Location: Gallatin, Tennessee

Monday-Friday 8:00am – 5:00pm shift (or as determined by office location hours)

This is a salaried position.

Excellent and comprehensive benefit package.

Please submit your application via this link.  If the link does not work, go to www.ascensionhealth and search for Job Opening 179637, RN/RN Case Manager-Ascension Care Management.

At Ascension Care Management we celebrate and support diversity of all kinds.

We are proud to be an equal opportunity employer.

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