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Country-wide Remote

US-Nationwide-FIELD

Full time

20190444

_What Individualized Care contributes to Cardinal Health_

Clinical Operations is responsible for providing clinical specialties support and expertise in the areas of advice and consulting, research and patient care to internal business units and external customers.

Individualized Care provides care that is planned to meet the particular needs of an individual patient.

_Job Summary_

The Individualized Care Nurse Care Manager provides a structured, patient-centered healthcare service by coordinating medical treatments, delivering patient education, and facilitating communication among patients, healthcare providers, and support systems. This role helps bridge gaps in care, promotes continuity of treatment, and supports patients in achieving optimal health outcomes.

_Responsibilities_

+ Collaborate with health care staff responsible for patient care to develop, implement, monitor and evaluate appropriate clinical care or other services to meet the needs of patients and coordinate all activities related to care management.

+ Strong working knowledge and basic medical management of chronic disease states, like cancer.

+ Ensures that areas of responsibility are operating in compliance, including documentation and records with all federal, state, and regulatory agencies.

+ Document all encounters and activities in the designated system accurately and in a timely manner

+ Participate in interdisciplinary case conferences and team huddles to ensure coordinated care as needed

+ Works with the oncology care team and internal care management team, identifies patients to be case managed, assesses patient's care requirements, modifies or coordinates modification of patient care and intervenes, as necessary

+ Coordinates in the development and review of clinical pathway trends and shares with appropriate service and management teams

+ Assist in quality improvement activities by identifying trends, barriers, and opportunities to improve program outcomes

+ Attends meetings, seminars, and conferences as appropriate

+ Principal and Chronic Care Management

+ Confirm member consent before enrolling them into the Care Management program and beginning outreach activities

+ Telephonically manage patient care, through the following methods:

+ Review of the patient's medical, functional, and psychosocial needs

+ Medication reconciliation with review for adherence

+ Reinforce disease self-management education and symptom management

+ Communicate oncology provider instructions and advice, and provide patient education materials

+ Referral to and coordination with community service organizations and make and/or specialist appointments and schedule other tests, treatments or procedures as needed

+ Facilitating patient follow-up visits with acute or chronic needs

+ Documents all concerns and follow-up and escalates to the onsite Clinical Team, or oncology provider when appropriate

+ Provide coaching and health promotion to encourage self-management and adherence to care plans

+ Manage a caseload size ranging between 100-150 members, and assist with other programs as needed

+ Collaborate with onsite clinical staff to order supplies for patients as needed (e.g., blood pressure machines, remote patient monitoring medical supplies)

+ Track and report on member progress, escalating complex cases to provider, the onsite clinical team or program leadership as needed

+ Transitional Care Management:

+ Attempt outreach to TCM members on the caseload via phone call as needed to support onsite TCM programs.

+ Assist with discharge planning: assess needs; help coordinate medication reconciliation; schedule TCM (Post -Acute) face-to- face visit with provider

+ Triage patient needs and identify necessary plan of action within such as scheduling an appointment, triaging for a provider or directing the patient to the ER, etc. as needed.

+ Bridge gaps between the onsite clinical team and the community, and ensuring patients fully understand their discharge instructions and follow-up care

+ Ability to collaborate effectively with the onsite clinical team/staff and remote care management team to support discharge planning, care transitions and ongoing care coordination interventions.

+ Basic computer skills including previous work with an electronic health record (EHR) and Excel spreadsheets

+ Must be highly motivated, result-oriented with strong skills in presenting, communicating, multi-tasking and time management

+ Ability to identify problems and recommend solutions

+ Ability to work independently with minimal supervision

+ Commitment to improving health equity and supporting vulnerable populations

+ Meets regularly with management team to discuss feedback from call monitoring and quality reviews. Discusses progress on productivity and quality goals.

+ Responsible for maintaining HIPAA guidelines.

_Qualifications_

+ Registered Nurse with a current, unrestricted Wyoming license or compact license in which Wyoming is included.

+ 5 years' experience-hospital or clinical, involving patients with complex chronic disease states preferred

+ Care Management experience is strongly preferred

+ Heavy oncology patient experience is strongly preferred

+ Experience with Microsoft Office products

+ Superior communication skills to include verbal and written

+ Must be able to work collaboratively; team focused

+ Excellent organizational skills

+ Bilingual skills a plus

_What is expected of you and others at this level_

+ Applies working knowledge in the application of concepts, principles and technical capabilities to perform varied tasks

+ Works on projects of moderate scope and complexity

+ Identifies possible solutions to a variety of technical problems and takes action to resolve

+ Applies judgment within defined parameters

+ Receives general guidance and may receive more detailed instruction on new projects

+ Work reviewed for sound reasoning and accuracy

TRAINING AND WORK SCHEDULES: Your new hire training will take place 8:00am-5:00pm CST, mandatory attendance is required.

This position is full-time (40 hours/week), Monday-Friday, 8:30am- 5:00pm MST.

REMOTE DETAILS: You will work remotely, full-time. It will require a dedicated, quiet, private, distraction free environment with access to high-speed internet. We will provide you with the computer, technology and equipment needed to successfully perform your job. You will be responsible for providing high-speed internet. Internet requirements include the following:

Maintain a secure, high-speed, broadband internet connection (DSL, Cable, or Fiber) at the remote location. Dial-up, satellite, WIFI, Cellular connections are NOT acceptable .

+ Download speed of 15Mbps (megabyte...

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