- Consistently exhibits behavior and communication skills that demonstrate Tandigm Health commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
- Provides complex care planning to high-risk patients in the community, meeting with them face to face before, during, or after PCP visits, according to established program protocols and policies.
- Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
- Coordinates and facilitates communications between all patient settings, including ambulatory, acute care, short stay, skilled nursing, palliative care and hospice.
- Conduct follow-up telephonic care calls to patients and families, as required.
- Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
- Reviews /triages PCP referrals to determine program and service needs of patients referred.
- Collaborates with the patient, family or caregiver, and the Tandigm PCP and office staff to help develop a POC customized to patient goals and needs.
- Implements POC in accordance with established policies, prioritizing patient care needs and meeting with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
- Maintains effective relationships with patients and families, PCPs and office staff, other providers, and community based agencies, facilitating interdisciplinary team meetings regularly.
- Consults regularly with the PCP, Tandigm Medical Director, Manager, and other team members to ensure that the POC remains relevant, appropriate, and responsive to changing patient status and/or goals.
- Leverages all available patient information available, including but not limited to PCP and hospital EMRs, maxMC, Athena, departmental databases, etc.
- When appropriate, conducts on-site or telephonic prospective, concurrent, and retrospective review of active patient care to evaluate goal progression and timely discharge
- When appropriate, coordinates treatment plans and discharge expectations and discusses DPA and DNR status with attending physician
- Participates actively in clinical rounds and/or case review meetings with Tandigm Medical Director, reviewing panel of high risk patients, including prospective and newly enrolled patients.
- Demonstrates a thorough understanding of the cost and quality consequences resulting from care management decisions
- Maintains accurate and complete records, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate databases.
- Initiates and oversees data entry into IS systems of all patients within the parameters of care management policies and procedures.
- Provides accurate information to patients and families regarding community resources, referrals, and other related issues.
- Uses, protects, and discloses Tandigm patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.
- A passion for community based, team oriented population health that is PCP led, patient centered, and focused on clinical and quality outcomes
- Excellent interpersonal communication skills and the ability to represent Tandigm Care Delivery Support in a community setting
- Proficiency in computer skills, including Microsoft Office, EMRs and other clinical databases; accuracy and attention to detail; ability to multi-task, i.e., chart clinical data during patient encounters.
- Pennsylvania RN license in good standing
- Reliable transportation with valid driver’s license and active automobile insurance
- Basic Life Support for Healthcare providers or CPR/AED for the Professional Rescuer
Position requires a Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college; Must be a graduate of an accredited school of nursing.
- Minimum of 5 years of nursing experience in an acute care setting.
- An additional 2 years of nursing experience in an ambulatory care or homecare setting
- Case management, utilization review, discharge planning, or nurse navigation experience.
- Experience working in a primary care physician office.
Knowledge, Skills & Abilities
- Customer-service oriented; responsive and respectful to colleagues, clients, patients, and providers.
- Ability to make sound, independent judgments and act professionally under pressure.
- Ability to effectively communicate and collaborate with physicians, other providers, patients, families, and ancillary staff.
- Knowledge of current best practice standards of patient care.
- Thorough understanding of, and compliance with, RN scope of practice in the Commonwealth of Pennsylvania.
- Excellent communication skills; ability to represent the organization to internal and external stakeholders with skill and confidence.
- Organized, detailed, and proactive; responds to requests in a timely and efficient manner.
- Collaborative and resourceful; functions successfully in a team environment as well as independently.
- Computer literate with proficiency in Microsoft Office suite of programs.
- Ability to type 45 wpm.
- Knowledge of medical terminology, CPT and ICD-10 coding.
- Knowledge of IPA/group internal processes and contractual agreements.
- Working knowledge of HMO/managed care/health plan.
- Manual dexterity to use/handle equipment and instruments.