Assist with delegation of assignments, scheduling and staff training. Provide care management and coordination activities for the patients of the primary care practice. This includes developing, providing and monitoring care management processes, as well as, coordinating and supporting primary clinical teams with these efforts. Identify high acuity patients and ensure care is appropriately coordinated for this patient population. Triage patients. Work with the practice manager and lead physician in the practice to best serve the needs of the patient panel and the primary care teams.
- Assist supervisor with the delegation of assignments, scheduling and staff training. Provide feedback during performance review process.
- Work with designated clinical teams to provide care management of patients, including pre-visit planning and post-visit summary review. Assist patients in setting SMART goals for self–management, teaching them self-management tasks. Report abnormal findings to their physician team.
- Partner with physician leadership to define quality measure/outcome reporting process and develop protocols and point of care reminders using nationally recognized EBC measure/outcomes (recommend starting with three clinically important conditions).
- Manage assigned panel of chronic care (high acuity) patients by developing relationships with the patient and providing follow-up contact to ensure compliance with recommendations (i.e. medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.). Manage referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.
- Provide telephone advice per protocol and handle urgent calls and emergent calls.
- Work with patient’s care team to coordinate change readiness, needs assessment and develop an individualized treatment care plan. Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals. Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments and work with care team to determine next steps.
- Serve as a resource to clinical staff and providers to establish quality goals using reports. Oversee the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams. Collaborate with payer Case Managers for additional services when appropriate.
- Develop a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
- Work with appropriate parties to coordinate efficient consult request communication and consistent documentation of patient self-management measures which entails a mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals.
- Partner with consulting physicians, hospitals, ER and other frequently used healthcare resources to clarify roles, develop effective, efficient timely communication between PCP and these entities. Facilitate physician leadership to develop written agreements with consulting physicians and key facilities to define the roles and method of communication. Develop workflows and protocols within the PCP that ensure ER, hospital follow-up. Work with IT resources to facilitate registry reporting at the site & documentation of EBC in searchable fields.
- Perform other related duties as assigned that correspond to the overall function of this position.
- Licensed by the Oklahoma Board of Nursing as a Registered Nurse.
- Three (3) years of experience as a registered nurse.
- Current CPR (Healthcare Provider).
- Certified in Care Coordination and Transition Management (CCCTM) by the Medical-Surgical Nursing Certification Board (MSNCB) preferred.
- Home care clinical experience preferred.
Employees in this position are, or can be, required to possess the following physical capabilities:
- Lifting, carrying, pushing and/or pulling up to 100 lbs.
- Stooping, kneeling and/or crouching daily
- Standing or walking more than 3 hours a day
- Reaching, grasping, fingering, and/or feeling more than 5 hours a day.
- Visual acuity in order to correctly distinguish skin tone variations, evidence of IV infiltration, infection; able to read telemetry, blood pressure gauges, etc.
- Audio acuity in order to correctly distinguish various body sounds (i.e., respirations, heart tones, bowel sounds).
- Audio acuity to discern sounds made by various types of machinery or equipment that would indicate dangerous or improper operation
St. Anthony Hospital –
St. Anthony Hospital is a 601-bed regional referral facility specializing in cardiology, oncology, surgery and behavioral medicine. The hospital, established in 1898, is located in Midtown Oklahoma City and serves the needs of Central Oklahoma, as well as many counties throughout Oklahoma, through its large rural affiliate network of hospitals. Four St. Anthony Healthplex campuses provide convenient emergency and outpatient service access to the outlying communities of the metropolitan area. St. Anthony added urgent care services in May 2015 at St. Anthony North. St. Anthony has received numerous awards including the Oklahoma Quality Award for Excellence, Certified Healthy Business, Premier QUEST® Award for High-value Healthcare Citation of Merit, among others. Healthsights ranks St. Anthony at performance levels for quality and patient satisfaction higher than local competitors and many national health care organizations.