Assist primary care practices to build sustainable, quality-driven care delivery processes through evaluation and coaching of patients with chronic medical conditions; oversees data capture and analysis to identify gaps in care delivery; implements and teaches quality improvement (QI) methods to close gaps and improve the practice’s ability to effectively manage its patient population through data analysis and process redesign.
Performs assessment and evaluation of patients with chronic disease per client contractual obligations. Collects detailed information including medical, social and financial information to aid in facilitating the appropriate treatment plan consistent with the patient’s needs. Collaborates with health care providers and ancillary service providers to validate the appropriate treatment plan and identify educational opportunities.
Ensures data necessary to report standard measures is collected as discreet data elements in the EHR or disease registry database. Works with EHR or registry vendor to obtain data output files in defined formats.
Actively engages with patients and families, utilizing motivational interviewing techniques; teaches self-management skills and supports patients and families with chronic disease. Coordinates care management activities across the care continuum.
Implements and teaches quality improvement methods including Plan, Do, Study, Act and use of data to office/clinic personnel and clinicians; ensures appropriate composition of the QI team including clinical champion(s).
Assembles data and information for regular reporting requirements maintaining confidentiality and sensitivity of protected health information.
Performs miscellaneous duties as assigned.
Two or four year degree in health care or related field and/or equivalent training and/or experience; Current RN license in the state where services will be provided dependent on client requirements; Minimum 3 years clinical practice experience preferred; Certified Case Manager or similar advanced credentialing or ability to obtain certification within 2 years of hire.
Experience with motivational interviewing preferred.
Positions working on specific contracts may require U.S. Citizenship.
Telligen and its affiliates are Affirmative Action, E-Verify Participants and Equal Opportunity Employers.
Sensitivity level of information handled in position: medium