GENERAL DESCRIPTION OF POSITION
Promotes the mission and vision of North Country HealthCare (NCHC) by collaborating within the Care Teams to provide care management services. Understand and utilize the Patient Centered Medical Home (PCMH) dynamic team approach and assist patients in optimizing health and minimizing barriers.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Provide care management, care coordination, and health coaching for the purpose of empowering patients to improve health.
- Develop, prepare, plan, and teach culturally appropriate self-management goals, health literacy, and disease prevention to particularly vulnerable populations and/or those who have multiple co-morbidities and/or are high utilization of services.
- Actively participate with the care team, supporting and engaging patient-centered, provider guided treatment goals. Create self-management goals using the foundations of Motivational Interviewing and a resiliency-based approach.
- Collaborate with patients experiencing a recent episode of care within the hospital and/or Emergency Department to assure appropriate follow-up care.
- Assist with pre-visit preparation planning for patients prior to appointment, as best practice mandates, to close gaps in care, plan for preventative care, and address any outstanding referrals.
- Document all encounters in the patient chart within the Electronic Health Record.
- Have an understanding and general knowledge of behavioral health diagnoses. Be able to create a professional rapport and supportive care within a medical setting.
- Conduct interviews to assist patients in identifying barriers to care and social determinates of health, have the ability to work within a multi-disciplinary team, and appropriately refer patients to community resources.
- Maintain a current list of community agencies and resources.
- Collaborate with Health Plans, hospital personnel, emergency room personnel, Behavioral Health Agencies, and community networks to provide optimal care management services and access to care for patients.
- Participate in the Quality Management Program through process improvement opportunities and incident reporting.
- Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting.
- Other duties as assigned.
- Currently licensed RN or LPN
- Four (4) year college degree, or equivalent experience resulting in broad knowledge of a field related to the job, such as nursing, health promotion, public health, or other human services field plus twelve (12) months related experience or training. Or equivalent combination of education and experience. Minimum one (1) year experience working in health care environment.
Compensation and Benefits:
- Medical insurance starts Day One for less than $5 per paycheck!
- 22 days of combined sick and vacation leave, plus 6 federal holidays, in first year
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