Schedule: Regular Full-time
Oversee clinical care to patients requiring care in post –acute care settings. Serves in an expanded nursing role to collaborate with the Medical Team to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Promotes integration of evidence based clinical guidelines, preventive guidelines, protocols, and data analytic metrics into the development of treatment plans that are patient-centric. Reports to: Regional Manager, Care Coordination for Beacon Health, LLC.
•Manage utilization and clinical metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population.
•Monitor patient progress and promote early intervention in evolving acute care situations.
•Provide safe transition of care across the continuum of care.
•Provide patient-centric education.
•Promote patient independence and self-management.
•Responsible for the assessment, planning and implementation process for a select group of patients in the post-acute setting.
•Demonstrate autonomy and accountability.
•Actively negotiate and influence individual and group decision- making.
•Adapt to a fluid, dynamic and rapidly changing environment.
Demonstrate leadership qualities in the areas of time management, problem solving, decision making, priority setting, delegation, organization, written/verbal communication and listening skills.
•Implement monitoring systems for patients requiring post-acute care settings; including the transition to and from, and during their care in the post-acute care setting.
•Continuously evaluate laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for population.
•Provides regular progress updates to PCP and other members of the care team.
•Collaborates with the care management teams across the care continuum to ensure smooth process in place when movement between settings occurs.
•Collaborates with post-acute providers and facilities to maximize clinical, quality and fiscal outcomes for the population.
•Interface with payers and participate in payer learning activities.
SKILLS AND ABILITIES:
Needs to be professional as well as knowledgeable, responsible, and accountable to manage patient care over the continuum and to assist in improving quality, cost, and patient/service satisfaction outcomes.
Organized, self-motivated and prioritize competing duties to complete projects within designated timelines.
Proficient in computer literacy including but not limited to the electronic medical record, electronic data entry, retrieval and report generation.
Demonstrates proficiency in basic computer skills, including accurate keyboard entry of data into relevant computer based databases and spreadsheets.
Demonstrates proficiency with Microsoft Word and Windows & Excel, and the ability to learn various system software. Demonstrates ability to use basic office equipment, computer, fax machine, copier, calculator, etc.
Work effectively with clinical and non-clinical staff.
Excellent communication skills.
Perform multiple tasks simultaneously.
Work with people from diverse backgrounds and experiences.
Ability to openly address and acknowledge observed issues and concerns.
Provide regular on-site visits to post-acute facilities throughout Beacon Health.
EDUCATION AND/OR EXPERIENCE:
Active Maine RN license or eligibility to obtain required.
At least three (3) years' recent acute care (or relevant) nursing experience required.
Knowledge of the basic principles of care management and care coordination required.
BLS Certification required.
Experience in care management/care coordination to include care planning, resource management, and utilization management desired. Prior experience in Post-acute setting desired.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.
Healthcare | Nursing