Methodist Health System
Healthcare
ACORNCaseManagereneficiaryCareNavigator
“ACO RN Case Managereneficiary Care Navigator at Methodist Health System. Skills: Care Management, Patient Education, Collaboration. Carry a caseload taken from a population of individuals whose disease acuity has been determined to be moderate to severe. Achieving system goals of improving clinical outcome for patients with chronic diseases by using timely and appropriate coordination of quality healthcare services to meet an individual’s specific health needs to promote positive outcomes”
What You'll Achieve.
improving clinical outcome for patients with chronic diseases; promote positive outcomes; achieve maximum levels of wellness and independence
Industry & Context.
Assess barriers when patient has not met treatments goals
What They're Looking For.
Must Have
Current Basic Life Support Certification required, Current license to practice professional nursing in the state of Texas required
Nice to Have
Bachelor of Science in Nursing preferred or equivalent professional experience in provision of Primary Care with this population is highly desirable, Advanced Cardio Life Support Certification preferred, Bilingual (English/Spanish) a plus
What You'll Do.
Carry a caseload taken from a population of individuals whose disease acuity has been determined to be moderate to severe
Achieving system goals of improving clinical outcome for patients with chronic diseases by using timely and appropriate coordination of quality healthcare services to meet an individual’s specific health needs to promote positive outcomes
Assess barriers when patient has not met treatments goals
is not following treatment plan of care
or has not kept important appointments
Assist patients in setting SMART goals for self –management
teaching them how to do self-management tasks and report abnormal findings to their physician team
Collaborate with payer Case Managers for additional services when appropriate
Collaborate with physicians
and practice staff in identifying appropriate patients for care management
Collaborate with the patient
and other care team members in assessing the patient’s progress toward individual health care goals
Consistent documentation of patient self-management measures
mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals
Develop a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently
Overseen the development
and adoption of patient self-management educational resources used by the primary clinical teams
Promote patient self-management and empowers patients/families to achieve maximum levels of wellness and independence
Provide follow-up contact with patient as indicated to ensure compliance with recommendations — medications
Responsible for being available to provide telephone advice per protocol
handle urgent calls and emergent calls
Utilize the Institute for Healthcare Improvement (IHIs) Chronic Care Model as foundation and framework for chronic illness care management
How You'll Work.
Team & Collaboration
Work closely with clinical support staff, nursing leadership, physicians, quality department, and the information technology department; Collaborate with payer Case Managers for additional services when appropriate; Collaborate with physicians, providers, and practice staff in identifying appropriate patients for care management; Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals
Communication Scope
Excellent communication and interpersonal skills; Good oral, written and presentation skills
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