•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.
•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.
•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 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, Essette, NextGen, 4UM, 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.
•Accuracy and attention to detail
•Ability to multi-task within separate databases and documenting patient data during patient encounters
•Pennsylvania RN license in good standing
• Basic Life Support for Healthcare providers or CPR/AED for the Professional Rescuer
Education and Experience
•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 preferred with;
• Acute care and Home care experience; with Case management, or formal nurse navigation experience.
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