Ambulatory Complex Care Coordinator

TriHealth•Cincinnati, OH

5h•Remote

About The Position

The goal of Ambulatory Complex Care Management is to help patients reduce ED and inpatient admissions and avoid re-admissions through longitudinal care management interventions that increase patient self-management activities of chronic diseases thereby improving quality of life. The Ambulatory Complex Care Manager supports the TriHealth Primary Care Physician practices utilizing clinical nursing skills to provide care management and make transition of care calls to value based patients discharged from inpatient and emergency hospital settings.

Requirements

Associate's degree or diploma in Nursing
RN, Registered Nurse
Progressive experience as a RN in a hospital, ambulatory or home health setting
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
2-3 years experience Clinical Nursing Hospital nursing
2-3 years experience Clinical Nursing Care Management, Home Care

Nice To Haves

Care management experience is preferred
Epic experience is strongly preferred

Responsibilities

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.
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.
Collaborates with the interdisciplinary team and Primary Care Providers consistently and professionally. Communicates with their enrolled patients on a consistent basis and this is documented in the EMR in a standard way utilizing smart phrases.
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.
Completes all departments 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.