- Facilitates efficient care for targeted Erickson Advantage health plan members in a variety of settings, focusing on returning the member to the safest and highest level of independence possible. The Care Coordinator utilizes a variety of interventions and coordinates care for targeted health plan members with a variety of providers, in a variety of care settings.
- Works closely with members who have multiple or poorly managed chronic disease/s. as defined target diagnoses in the health plan Policies and Procedures.
- Assesses the high risk member’s current medical circumstances, provides information about health care options, serves as guide and advisor to the patient and his/her family, and establishes and molds the relationship with the primary care physician and the patient. Through risk stratification, high risk members will be identified, and a case opened for members who meet criteria for care coordination services.
- Works with the primary care physician to establish protocols for routine and preventive care which reflect accepted standards of care. Facilitates development of customized care plan through collaboration between the, primary care physician, the health plan member, and other health care team providers including specialists, vendors, and ancillary healthcare providers. As a member of the care delivery team, works to facilitate health plan member compliance and ensure continuity of care per the team’s “care plan”.
- Care Coordinator will measure case performance based on program goals, objectives, quality indicators, and patient specific outcomes.
- Researches and selects care options as appropriate. The nurse care coordinator may utilize a range of alternative, non-medical services (i.e., diabetic education, cardiac rehabilitation and dietary instruction) and treatments. The care coordinator may also make recommendations for alternative medical care for approval by the primary care physician.
- Assists health plan members and their families in selecting care options by providing information about providers, services and treatments, risks and potential results involved with options.
- Maintains a comprehensive, computerized medical and social history for assigned patients. Information will be used for such activities as patient assessment, care planning, patient/care evaluation, case tracking, and risk prediction, as well as cost analyses. Software system will be utilized to enhance communications among the health care team.
Knowledge of health care and insurance industries and health care delivery systems. This includes current standards of medical practice; insurance benefit structures and related legal/medical issues; and utilization review and quality assurance procedures.
Computer skills for documentation purposes, and ability to use a variety of software (database and spreadsheet) applications to maintain records, analyze alternatives, evaluate trends, and to assist in problem-solving and decision-making responsibilities.
Business acumen so that health benefits and patient satisfaction are maximized, cost-effectiveness realized and the Program’s viability is solidified.
BS preferred; Active Professional Licensed RN required. CCM certification or working toward.
Minimum 5 years clinical experience (medical/surgical, community health nursing, home health care) and/or 3 years case management and/or UR experience preferred.