This is an EMHS position located at an Inland Practice in the Waterville, Maine area.
Oversee clinical care to patients requiring care in a post –acute care settings. 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.
· Manage utilization and clinical metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population.
EDUCATION AND/OR EXPERIENCE:
- 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.
- Implement monitoring systems for patients requiring post-acute care settings; including the transition to and from, and during their care in the post-acute care setting.
- 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.
- Collaborates with post-acute providers and facilities to maximize clinical, quality and fiscal outcomes for the population.
- Interface with payers and participate in payer learning activities.
· RN - State of Maine Board of Nursing required
· Bachelor's degree in Nursing preferred
· Three to five years of recent (within the last 3 years) acute care experience or relevant experience required.
· Knowledge of the basic principles of care management and care coordination required.
· BLS Certification required.
· Experience in care management/care coordination to include care planning, resource management, and utilization management desired.
· Pediatric nursing experience desired.
· Prior experience in Primary Care setting desired.
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 post-acute 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.
Demonstrates the 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.
Ability to provide regular on-site visits to post-acute facilities throughout Beacon Health.
Must pass background check.
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.
Demonstrated ability to complete projects within designated timelines and the ability to prioritize duties is required.
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.
**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.