Job Title: Registered Nurse Telephonic Case Manager
Status: Exempt
Reports To: Clinical Service Manager
Department: Care Delivery
Date: May 2021
Location: Remote

About PopHealthCare Value-Based National Medical Group: Our mission is simple leading the effort to reimagine how health care is delivered for our nations most vulnerable seniors and adults. Improving the lives of those most in need guides everything we do, and we believe that as we continue to stay focused on that compass heading we will increasingly be recognized as Americas leading national medical group providing in-home and virtual care for those most in need.

Our care delivery model is proven. For more than seven years PopHealthCare Teams have been delivering the Triple Aim (enhancing patient experience, better care, lower total cost of care) for those most in need living in ethnically and geographically diverse communities- from urban Baltimore, to rural central Florida, to upstate New York and across Arizonas Maricopa County, we are proud of our achievements. While delivering exceptional patient experience (2020 enterprise wide NPS of 82) we lower the total cost of care (~15-20% across markets), and keep it lower, by delivering more care, not less.

We have brought the same focus to the experience of our own team members as we have to our patients, and through the prioritization of Joy In Work have made the Quadruple Aim in health care delivery our clinical true north.

PopHealthCare core care teams are multi-disciplinary and include Community Health Workers (CHW), Registered Nurses (RN), Advanced Practice Providers (APP- NP/PA), and complex care physicians (CCP), among other care coordination and specialized resources such as palliative care and behavioral health clinicians (Physicians and Advanced Practice Providers), as well as Social Workers (SW), Physical Therapists, and Registered Dieticians (RD).

Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible- home-based advanced care. Advanced care is comprehensive, and includes medical, behavioral, and social care, and can be delivered either as advanced primary care where our care teams serve as the primary care team or advanced supportive care where our care teams work in partnership with patient PCPs to deliver an added layer of support.

Value-based payment methodologies allow our physicians and APPs both the time they need to restore the clinician-patient relationship, as well as ensure the patient and clinician are surrounded by a care team that is able to address all of their care needs, especially their behavioral and social needs.

Role Summary:

The Registered Nurse (RN) Telephonic Case Manager is a critical member of the CareSight team. He/she is responsible for telephonically assessing, planning, implementing and coordinating all case management activities for patients enrolled in the CareSight Program

Role Responsibilities:

• Uses clinical/nursing skills to help coordinate the patients treatment plan while ensuring quality and cost-effectiveness of care.
  • Review of labs/diagnostics and follow up
  • Monitor, identify and assess chronic exacerbations and acute changes of condition and refer to Provider as appropriate.
  • Assist in maintenance of the patients medication record
• Assess and identify barriers to care; determine goals, objectives, and potential alternatives to care. Advocates for the patients best interest; addressing treatment alternatives and coordination of quality, cost effective health care.
• Provides telephonic visits as requested by the Provider to assess for active conditions, adherence and response to treatment plan, and any changes.
• Provide patient education to assist with self-management, disease processes and healthy lifestyle options.
• Monitors, evaluates, and documents case management activities and outcomes including case management approaches, over or under utilization, effective and non-effective treatment, and non-compliance
• Collaborates with an internal and external multi-disciplinary team (MDT) to determine risk of adverse outcomes based on medical and social needs for the assigned caseload.
• Facilitates Advance Care Planning (ACP) with the MDT and identifies surrogate decision maker (MPOA, Health Proxy, etc.)
• Coordinate referrals to specialists and outside sources and other services as needed.
• Collects relevant data to complete forms for Prior authorization, medication refills, respite stays, FMLA, court forms, etc.
• Triage all patient calls utilizing standard triage protocol and follow up with Provider as needed
• Telephonic outreach to patients with recent discharge from acute setting
• Ensure records from past Providers, specialists, hospitals, etc. are reviewed and uploaded to EMR. Ensure Provider is aware of any urgent needs.
• Communicate effectively with entire CareSight Team
• Assists with implementation of orders as necessary.
• Documents all patient encounters (in-home and telephonic) per documentation standards
• Participates in clinical case conferences as required
• Coordinates and communicates with health plan case managers, facility staff and others involved in patient care

Role Qualifications:

We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion and perseverance to achieve long-term goals (a.k.a. grit), team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery system. Flexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovate health care delivery solutions. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Additional qualifications include-

• Holds active, unencumbered license in state of practice
• Professional RN with 3+ years of clinical nursing experience; preferably in the care of chronically ill adult patients.
• Strong organizational skills and multitasking abilities
• Effective problem solving and appropriate application of clinical knowledge
• Intermediate to advanced computer skills and experience working with an EMR
• Effective communication and interpersonal skills
• Certified Case Manager (CCM) preferred

PopHealthCare is an equal opportunity/equal access employer fully committed to achieving a diverse workforce.