||This is a Beacon Health position located at within the Maine Coast Memorial Hospital Primary Care Practices JOB SUMMARY: Oversee clinical care to outpatients with chronic disease. Serves in an expanded nursing role to collaborate with the Medical Team to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Integrates evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Reports to: Regional Manager, Care Coordination for Beacon Health, LLC.PRIMARY RESPONSIBILITIES:· Manage utilization and practice metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population· Monitor patient progress and promote early intervention in acute care situations· Provide safe transition of care across the continuum of care· Provide patient education· Promote patient independence and self-management· Demonstrate autonomy being accountable for their practice· Demonstrate the ability to negotiate and influence individual and group decision- making. · Adapt to a fluid, dynamic and rapidly changing environment. · Demonstrate leadership qualities in the areas of time management, problem solving, decision making, priority setting, delegation, organization, written/verbal communication and listening skills.· Works with Beacon Health leadership in the design, implementation and evaluation of the Medical Home care model.· Implement monitoring systems for high-risk member to prevent and/or intervene early during acute exacerbations. · Works with the primary care physician to ensure appropriate standing orders for acute exacerbation management (such as diuretic titration protocol).· Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population.· Provides regular progress updates to PCP and other members of the care team. · Collaborates with the Transitional Care Coordinators to ensure smooth process in place when movement between settings occurs.SKILLS AND ABILITIES:· Needs to be professional as well as knowledgeable, responsible, and accountable to manage patient care over the continuum and to assist in improving quality, cost, and patient/service satisfaction outcomes. · Will be responsible for the assessment, planning and implementation process for a select group of patients in the outpatient setting.· Must be organized with the ability to self-motivate and prioritize a variety of duties.· Proficient in computer literacy including but not limited to the electronic medical record, electronic data entry, retrieval and report generation.· Ability to work effectively with clinical and non-clinical staff· Demonstrates excellent communication skills and ability to perform multiple tasks simultaneously. · Ability to motivate others· Ability to work with people from diverse backgrounds and experiences· Ability to openly address and acknowledge observed issues and concerns· Demonstrates proficiency in basic computer skills, including accurate keyboard entry of data into relevant computer based databases and spreadsheets, · Attention to detail, and ability to be flexible in performing a variety of tasks. · Demonstrates proficiency with Microsoft Word and Windows & Excel, and the ability to learn various system software.· Demonstrates ability to use basic office equipment, computer, fax machine, copier, calculator, etc.· Demonstrated ability to complete projects within designated timelines and the ability to prioritize duties is requiredEDUCATION AND/OR EXPERIENCE:· Registered Nurse with three to five years of recent (within the last 3 years) acute care experience or relevant experience required. · Bachelor's degree in Nursing preferred· Knowledge of the basic principles of care management and care coordination required. · BLS Certification.· Experience in care management/care coordination to include care planning, resource management, and utilization management desired. · Prior experience in Primary Care setting desired. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.