Ambulatory Complex Care Coordinator - RN - TriHealth Center for Health Equity

TriHealth•Cincinnati, OH

10d•Onsite

About The Position

Join TriHealth's Center of Health Equity as a Registered Nurse Care Manager and make a meaningful impact on the lives of patients with complex health needs. Working closely with providers and interdisciplinary teams, you'll help patients navigate their healthcare journey, manage chronic conditions, overcome barriers to care, and achieve healthier outcomes. Through compassionate care coordination, education, and advocacy, you'll help advance our mission of improving health equity across the communities we serve.

Requirements

Associate's Degree or diploma in Nursing (Required)
2 - 3 years experience Clinical Nursing Hospital nursing (Required)
2 - 3 years experience Clinical Nursing Care Management, Home Care (Required)
Strong oral and written communication skills as well as strong customer service skills with phone etiquette
Collaborates well with the interdisciplinary team
Proficient computer skills

Nice To Haves

The Care Manager has attended MOLST training.

Responsibilities

Collaborates with the interdisciplinary team and Primary Care Providers consistently and professionally.
Communicates with their enrolled patients on a consistent bases and this is documented in the EMR in a standard way utilizing smart phrases.
Maintains their panel of patients , completing assigned outreaches at the intervals they are due, and manages using evidence-based care such as Standards of Practice for Case Management, NCQA Standards for Care Management and program description.
Utilizes both clinical and claims reports, discharge reports, predictive modeling reports to identify patients that would benefit from enrollment into the programs.
Completes all department assigned and mandatory education and attends at least 75% of the monthly department meetings.
Attends daily huddles, has their camera on when required, is available and active on web ex and e-mail throughout the working day, is responsive to calendar invitations and attends scheduled meetings on their calendar on a consistent basis.
Ensures enrolled patients have a documented attempt for advanced care planning discussion, and this is documented in the EMR. Appropriate resources are sent to the patients and consults are made for assistance with ACP as needed. RN Care Managers provide education to patients and their families on the importance of ACP and encourage them to complete these documents and provide copies for the EMR. The Care Manager has attended MOLST training.
TOC: Enrolls a large population of targeted patients with specific insurance contracts into the TOC program, makes scheduled outreach calls and schedules PCP follow-up appointments for these patients within specified timeframe thereby reducing re-admissions.
Refers patients to CCM on a consistent basis.
CCM: Enrolls patients, creates care plans, makes monthly follow-up calls and dis-enrolls patients once patients meet goals and/or before target date. Follows NCQA guidelines, policies and procedures, and program description. RN's make appropriate referrals and document using standardized smart phrases.
Manage Medicaid patients with: Blood Pressure >140/90 A1C >8
Conduct clinical assessments
Review clinical data and risk stratification
Support chronic disease management plans
Medication adherence monitoring
Provide health literacy education
Develop individualized care plans
Coordinate with primary care providers and specialists
Monitor clinical outcomes and progress