GENERAL SUMMARY: Partnership for Community Care is one of 14 similar, non- profit corporations that was established for the purpose of improving the health outcomes and reducing the care costs of the Carolina Access II and Aged, Blind, Disabled, Medicaid populations in Guilford, Randolph and Rockingham Counties. The network is comprised of Nurses, Socials Workers, Pharmacists, Nutritionists, Providers, and Administrative Professionals, who work collaboratively to manage chronic disease in the Medicaid population. The role of the Clinical Care Coordinator is to provide support to the RN Care Manager in the holistic multi-disciplinary team approach, which includes social and emotional assessment, planning, facilitating, education and advocacy for the patient protocols. The Clinical Care Coordinator must be able to communicate effectively with patients, providers, and other members of the care team, to include, but are not limited to, DMA, DSS, and local health departments. The LPN will accept delegated tasks from the appropriate members of the team under the direction of the Registered Nurse, according to the North Carolina Board of Nursing Scope of Practice for Licensed Practical Nurses, to facilitate disease management practices according to the standardized plan of Care Management from Community.
ESSENTIAL JOB FUNCTIONS:
- Outreach to patients with multicultural and diverse socioeconomic backgrounds, who have chosen Carolina Access II providers within the Partnership for Community Care Network under the supervision of the Registered Nurse.
- Review data and claims provided by CCNC data sources to identify and determine appropriateness for care management, which includes monitoring utilization, reporting, and compliance issues
- Maintain current and ongoing records of all case management tasks and activities in the CMIS program to assist members of the care management team.
- Encourage, Empower and Educate patient to the self- responsibilities of chronic disease management utilizing network provided self- management tools and approved best practice models based on CCNC guidelines. Maintain and appropriately document confidential HPI of patients, in a timely manner, in Case Management Information System (CMIS)
- Maintain and appropriately document confidential HPI of patients, in a timely manner, in Case Management Information System (CMIS).
- Participate and attend staff, medical management, workgroup, community collaborative, and interdisciplinary team, meetings as identified.
- Communicate openly and professionally with patients, providers, multidisciplinary care team members, as well as administrative staff in the healthcare setting.
- Works collaboratively with Multi-disciplinary team members to facilitate patient- centric care plans, incorporating disease management practices, according to CCNC standards for care management.
- Follow up with incoming Out of Network referrals according to process to insure establishment and or continuity of care for case management of patients to assigned pended PCM.
- Responsible for assisting with uploading appropriate HPI documents provided by RN/PCM into patient CMIS document record.
- Telephonic outreach to patients with recent ED utilization within 24 business hours of notification.
- Collaborate with PCM to provide Case management services with guidance and collaboration from Primary Care Providers
- Follow-up on all issues identified by the referral from the CCNC Call Center.
- Contribute to the development of a plan of care for those identified populations.
- Provide assistance to Chronic Disease Nurse with Tele-monitoring Program
- Manage remote monitoring system to assist with tracking chronic care patient’s progress as it relates to their disease process, when needed as support role to Chronic Disease RN
- All other duties as assigned
KNOWLEDGE, SKILLS, AND ABILITIES:
- The ability to work within network setting , providing medical case management service to diverse population under the supervision of RN
- Ability to work within a flexible schedule.
- Maintain professional license and certification
- Knowledgeable of the roles of public and private agencies, the community and area resources available to meet patient needs, and compliance with applicable federal and state regulations
- Knowledge of NC Nursing Practice Act, Scope of Practice, and licensure governing boards; regulations and policies which also govern and affect the NC Medicaid programs
- Ability to plan and organize, think analytically, and utilize time management skills effectively
- Ability to work professionally, communicate effectively and respectfully with others, and exercise good judgment in assessing situations to make informed decisions
- Elicit information, including confidential HPI according to HIPPA standards
- Maintain professional, effective working relationships with co-workers and members of the multidisciplinary team
- Comprehensive knowledge of nursing practice, theory and principles as well as the guidelines for evidence based, best practice medical standards, for treatment of stable, sub- acute, convalescent, and chronically ill patients
- Ability to communicate effectively and clearly, both verbally and in written communication; must possess ability to document and record accurate patient information as well
- General knowledge of Microsoft Word and Outlook; strong computer skills for data interpretation, documentation and communication.
- General knowledge of personal hygiene, basic health and safety practices and sanitation applicable to environmental/ work area.
- Must possess a valid driver’s license and vehicle for dependable transportation.
EDUCATION AND EXPERIENCE:
- LPN Degree with current NC licensure from NC Board of Nursing
- Greater than 5 years of Clinical Utilization Management, Discharge Planning, Home Care, Long Term Care, Acute Care Facility and/or Ambulatory Care/ Physician’s Office experience.
- Case Management experience is preferred
- Licensure in the State of NC with Nursing Board
- Excellent interpersonal communication skills
- Clinical competence in applying techniques of assessing psychosocial, behavioral, an psychological aspects through patient/ client interview
- Strong organizational, analytical and time management skills
- Strong computer skills
PCC in partnership with Supporting People help these young people ahieve independency. In the past young people leaving care used to be...