PURPOSE: Provides complex care management in collaboration with health plan medical management for patients who agree to Sansum Clinic’s ACO engagement letter, of ongoing outreach and care navigation. Serves as a consistent care navigator throughout the continuum of care, for the engaged ACO patient with multiple, ongoing medical and social concerns. Serves as a liaison between the patient, Primary Care Physician, and the various healthcare providers and departments/facilities required for proper diagnosis, treatment and management of the complex clinical conditions. Offers care transition support and ongoing communication with PCP, through regular communication and/or case conferences for ongoing care coordination of the PCP’s patients. Focuses on achieving improved patient outcomes by monitoring and assisting with navigating the healthcare resources available for their complex conditions. In addition while ensuring the following: improved clinical quality measures, reduction of hospitalizations/re-admission rates, in/outpatient cost effective resource utilization within the health plans contracted network of providers/facilities, improved patient satisfaction, etc. SUMMARY OF ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Analyze and evaluate health plan data and medical record data of the engaged ACO patient to determine most appropriate outreach (e.g., phone outreach, face to face appointment during a primary care physician visit, home visit) and develop a care plan for that patient. 2. Promote a collaborative relationship with the Sansum medical community, especially Hospitalists, SNF providers, primary care providers and all other members of the health care team, including ancillary services such as pharmacy, diabetic educators, nutritionists, social workers, ACC Clinic, oncology navigators, health educations, community resources etc. to develop… For full job description and to apply, go to www.sansumclinic.org/careers.
QUALIFICATIONS: Must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and abilities of personnel placed in similar or the same positions.
>Must be able to read, write, spel
- 20 months ago - save job