- Consistently exhibits behavior and communication skills that demonstrate Tandigm Health’s commitment to superior customer
service, including quality, care, and concern for all internal and external customers.
- Serves as primary point of contact for patients and their PCP’s.
- Performs initial case management assessments and determines their patients’ “current state” by evaluating their physical,
psychological, social, environmental, financial, and functional status, as well as the strength of their support system.
- Develops multidisciplinary care plans that address key needs for each patient in their panel; the plans incorporate feedback and results from assessments conducted over the phone by the Nurse Care Manager or in-person by other CCM members (e.g., NPs, Field-Based Nurses, Social Workers).
- Coordinates key logistical activities and elements of each care plan, delegating to CCM members, as appropriate.
- Identifies and monitors the status of high-risk patients.
- Serves as the primary point of contact for patients’ medical needs; provides telephonic support, education, monitoring, and assistance to patients and caregivers.
- Consults regularly with Tandigm staff, Tandigm Medical Directors, and PCP’s, as appropriate, to ensure that the care plan remains relevant, appropriate, and responsive to changes in patient status and/or goals.
- 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.
- Maintains effective relationships with patients and families, PCPs and office staff, other providers, and community-based agencies.
- Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability
and Accountability Act (HIPAA) standards.
- Completion of a Bachelor of Science in Nursing (BSN)
- Minimum 5 years of relevant clinical experience in a hospital, clinical, or home care setting is required
- Minimum 3-5 years of case management (CCM certification preferred), disease management, utilization review (guideline knowledge preferred), and transition of care experience is required
Knowledge, Skills, Abilities
- Ability to analyze and interpret clinical data
- Strong organization and planning skills
- Strong ability to interact and communicate effectively with patients to establish trust and create meaningful relationships to maximize likelihood of patient adherence to the care plan
- Ability to work telephonically and with the addressable population across the member base
- Commitment to act and speak in accordance with Tandigm Health mission and values
- Language skills to support multilingual needs across the member base
- Current and unrestricted Pennsylvania RN license in good standing
- Case Management Certification a plus
- Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
- Driver’s License in good standing
- Ability and means to travel on a flexible schedule as needed throughout the five county Philadelphia, PA region, proof of liability and property damage insurance on vehicle used is required
Physical Requirements in Accordance with ADA
- Carrying/Lifting: Occasional, 0-25 lbs.
- Standing: Frequent, up to 6 hours per day
- Sitting: Frequent, up to 6 hours per day
- Walking: Frequent, up to 6 hours per day
- Repetitive Motion: Keyboard activity, telephone use, writing, reaching, grasping, pushing, pulling
- Visual Acuity: Ability to view computer monitors and read newsprint, with or without corrective lenses
- Environmental Exposure: None