Overview

Provides comprehensive care management and transition of care services within a multidisciplinary team to improve quality, reduce cost, promote optimal patient health and well-being across the continuum of care and promote patient and provider satisfaction. Utilizes data analytics, population health principles, and quality measures to facilitate delivery of high quality, cost effective, patient-centered, holistic care to optimize patients' health and health outcomes. Implements the case management process to assess, plan, implement, coordinate, monitor, and evaluate resources and services to promote optimal health and health outcomes of high risk, complex patients. Delegates care plan tasks to appropriate care team members. Collaborates with providers, practices, care team members, community agencies, and patient support networks. Promotes optimal health and self-management through advocacy, empowerment, multi-modal communication, education and coaching, identification of and connection with resources, facilitation of efficient service delivery, and promotion of a positive patient-PCP relationship. Supports providers and practice's ability to deliver quality care and care management services. May include home, community, inpatient, and/or ambulatory-based patient encounters. Accountable for consistently achieving quality metrics.
Department Description


Licensure

Registered Nurse Required - And Accredited Case Manager Or Certified Case Manager Required
Education

Bachelor's Degree Nursing Required
Experience

6 Years Nursing Required