- 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.
- Supports the nursing process telephonically according to the policies and procedures set by the department, assessing the needs of patients and developing POC in conjunction with PCPs.
- 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.
- Implements POC in accordance with established policies, prioritizing patient care needs and discussing them with patients, and/or patients’ family/caregivers as needed and appropriate, to promote understanding and adherence.
- Evaluates patient progress against patient Plans of Care, documenting updates per protocol in the appropriate clinical database.
- Accepts responsibility for patients’ Transitions of Care, coordinating provisions for follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
- Reviews /triages PCP referrals to determine program and service needs of patients referred.
- Accepts incoming patient referrals within the specified care management policy timeframe, enrolling patients in programs as appropriate and documenting activity per departmental protocol.
- Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
- Identifies and monitors the status of high-risk patients in acute care settings, skilled nursing facilities, custodial, and ambulatory settings, facilitating optimal care coordination and communicating patient outcomes to all stakeholders in a timely fashion, per established protocols.
- Maintains effective relationships with patients and families, PCPs and office staff, other providers, and community based agencies, facilitating interdisciplinary team meetings as needed.
- 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.
- Utilizes all available patient information as appropriate, including but not limited to PCP and hospital EMRs, maxMC, Athena, and departmental databases.
- When appropriate, conducts on-site or telephonic prospective, concurrent, and retrospective review of active patient care to evaluate goal progression and timely discharge.
- Identifies patient and family goals and expectations regarding treatment plans; and when appropriate, discusses Advance Directives with PCPs, other providers, and/or patients and families.
- Participates actively in clinical rounds and/or case review meetings with Tandigm Medical Director, reviewing panel of 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, documenting pertinent patient information, patient and PCP communications, and all care management activity in the appropriate databases and 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
- Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
- Graduate of an accredited school of nursing.
- 3-5 years of nursing experience in an acute care setting.
- 2 years of nursing experience in an ambulatory or home care setting
- The above minimum experience along with 3+ years of case management, discharge planning, nurse navigation, or homecare experience.
Knowledge, Skills and 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