Registered Nurse - Population Health Care Manager - DayLocation: WellSpan Health, York, PASchedule: Full TimeScheduleFull Time: 80 Hours/BiweeklyHours: 8:00am - 4:30pmGeneral SummaryCoordinates and monitors the health needs of patients under value-based care risk arrangements, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. This position works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient's maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. This position ensures patient's cases are in compliance with regulatory guidelines.Duties and ResponsibilitiesEssential Functions:
Utilizes Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management of their chronic conditions with the goal of improved symptom management and interruption of a negative disease trajectory.
Maintains a caseload of patients according to department policies.
Meets patients in their home, primary care office, and other locations as identified.
Identifies, enrolls and manages patients in program for Complex Case Management/Chronic Disease Management.
Provides transitions of care outreach for patients at high risk for readmission and either continues to follow the patient for needed complex care management, or ensures patient receives health coach or technology support to ensure positive health outcomes.
Develops and implements care plans to maximize healthcare outcomes and facilitates wellness with periodic review and update according to department protocols.
Performs medication review and teaches-back to ensure patient understanding and ability to adhere to medical regimen.
Collaborates with PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
Performs patient outreach according to established protocols and document in electronic medical record.
Identifies, executes, and tracks needed referrals to care and community resources.
Provides resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
Assists patient in advanced care planning to complete Advanced Directives.
Documents member's assessments, care plans, goals and interventions in electronic medical management system according to NCQA standards.
Common Expectations:
Prepares and maintains appropriate documentation as required.
Maintains established policies and procedures, objectives, quality assessment and safety standards.
Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
Prepares and presents utilization data analysis as required.
Develops and initiates educational programs regarding utilization management principles.
Attends meetings as required.
QualificationsMinimum Education:
Associates Degree Required
Bachelors Degree Preferred
Work Experience:
3 years Nursing experience. Required
Utilization Management, Case Management or Clinical Nursing specialty experience. Preferred
Licenses:
Licensed Registered Nurse Upon Hire Required or
Registered Nurse Multi State License Upon Hire Required and
Basic Life Support Upon Hire Required
Courses and Training:
Residency in service area. Upon Hire Preferred
Knowledge, Skills, and Abilities:
Excellent communication and interpersonal skills.
Proficient in SBAR technique.
Ability to effectively present clinical information to the care team.
Proven organizational and motivational skills.
Ability to work cooperatively as part of a team.
Self-motivated and dependable.
Able to work independently.
Benefits Offered:
Comprehensive health benefits
Flexible spending and health savings accounts
Retirement savings plan
Paid time off (PTO)
Short-term disability
Education assistance
Financial education and support, including DailyPay
Wellness and Wellbeing programs
Caregiver support via Wellthy
Childcare referral service via Wellthy
Apply NowYou’re unique and you belong here.At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email atcareers@wellspan.org. We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.
