Chronic Care Management RN Advisor (Apply in minutes) - Irving - ref. k71590019

Description**

_Summary:_

outreach for assigned population.

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Fosters health risk reduction through goal setting, behavioral change, patient education, and identification of social determinants with appropriate community referrals.
• Focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and education patients regarding the appropriated setting for care.
• Promotes optimal person-centered care that supports and empowers individuals, respects individual choices, and meets patients health care needs.
• Completes initial assessment and plan of care including the patient, their support system, physician, and other health team members to address condition, social determinants, and promote patient knowledge and behavior change.
• Develops relationships with and facilitates referrals to community resources including Skilled Nursing, Rehab, Long Term Acute Care, Home Health, Hospice, Palliative Care, Transportation, Medication Asst., DME, and other community resources.
• Completes activities pertaining to and achieving quality measures related to payer contracts.
• Exhibits behaviors and actions which create a high level of patient satisfaction, contributes to positive patient relations, and reflects respect for a patient’s rights, needs, and confidentiality.
• Performs ongoing essential Care Management activities of assessment, barrier and strengths identification, planning implementation, coordination, monitoring, and evaluation of patients. Implements action to overcome barriers to care.
• Collaborates with team members in the discharge process, performing outreachdocumentation according to CMS guidelines and the Population Health workflow.
• Outreach to TOC patients should focus on medication reconciliationadherence, self-management, use of personal health records, follow-up with PCPsSpecialists, and review of indicators that a patient’s condition is worsening and how to respond.
• Promotes a positive work environment by displaying a caring, sensitive approach to others, as evidenced by listening, understanding, and responding to the needs of patients, colleagues, and supervisors.
• Ability to serve as a Patient Advocate, communicating high-levelly with patients and all levels of Associates across the organization.
• Performs other duties as assigned.

_Job Requirements:_

• Bachelor’s Degree in Nursing preferred.

• 3-5 years of clinical experience required.
• 2-3 years of managed care andor care management experience preferred.

• RN license in the state of employment or compact is required.

_Work Schedule:_

5 Days - 8 Hours

_Work Type:_

Full Time

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257-6925.