Ambulatory Chronic Care Manager

CAMERON HEALTH•Angola, IN

About The Position

The Population Health Nurse focuses on improving the health status and care of individuals with chronic health conditions, potentially complex medical, behavioral health, and psychosocial or social-determinant needs, as well as supporting transitional care management processes. The role provides individualized, patient-centered care coordination and works with patients, families, providers, care teams, payers, and community resources. The position identifies and engages eligible patients, assesses unmet health and social needs, develops and monitors individualized plans of care (LPOCs), supports health literacy, and helps patients navigate healthcare services and community resources. It coordinates access to medical and specialty providers and support services, supports transitions in care and medication reconciliation, and documents care and charges in a timely manner. The role also contributes to wellness strategies, program evaluation, continuous quality improvement, meetings, and ongoing professional development. This is a full-time, day-shift role in the Population Health department at Cameron Hospital in Angola, Indiana. The posting describes the physical demands as Level 3, Medium Duty.

Requirements

Graduate from an accredited nursing program.
Excellent communication skills.
Ability to multitask, organize, and complete assignments in a timely manner.
Ability to manage time efficiently with minimal supervision.

Nice To Haves

Care-management and patient-navigation experience.
Experience in a physician healthcare office.
Knowledge of local and regional community resources.
Competence with the Epic EMR system.
Bachelor's degree.
Advanced care planning certification.

Responsibilities

Demonstrate service excellence and provide excellent guest relations to patients, visitors, and team members.
Identify and engage patients who qualify for chronic care management and transitional care management.
Collaborate electronically and in person with patients and families to create individualized plans of care, including assessment of unmet health and social needs, health-literacy support, shared goals, emergency plans, medical summaries, and ongoing action plans as appropriate.
Help patients navigate the healthcare system and available resources; monitor adherence to plans of care and progress toward goals; and facilitate changes to care plans as needed.
Support ongoing processes through which patients and families can determine and request their desired level of care coordination support.
Facilitate access to appropriate medical and specialty providers and care-coordination support specialists, such as dieticians and pharmacy support.
Support primary care and subspecialty co-management through timely communication, inquiry, follow-up, and integration of information into care plans related to transitions in care and referrals.
Document patient care, condition, reactions, treatment response, and progress in a timely manner, and add appropriate charges to documentation.
Serve as a point of contact, advocate, and informational resource for patients, families, care teams, payers, and community resources.
Work with population health team members and other disciplines to provide comprehensive wellness strategies.
Facilitate or attend meetings as needed with patients, families, care teams, and community resources.
Identify transitional-care needs, complete medication reconciliation, and take steps to ensure effective transitions for patients and families.
Use interpersonal and observational skills to identify psychosocial adaptation to illness and possible psychopathology.
Apply contemporary health-behavior-change theories to help patients and family members reach established goals.
Collect and aggregate plan-of-care data to support program evaluation and identify improvement opportunities.
Participate in ongoing education, professional development, continuous quality improvement activities, staff meetings, and other required meetings.