Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients . We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The Clinical Nurse Supervisoris responsible, as part of the Market Leadership and care teams, for the overall patient Care Management process. The position reports to the Health Services Director and provides oversight, guidance and support for the processes related to the development, implementation and outcomes of member care plan as developed through clinician, CM and allied clinical support evaluation and physical risk assessment. The position provides support for the day to day operations including scheduling, outreach, and assignments. Working with the Health Services Director, their role would be to be the main contact for health plan referrals, inpatient notifications, interdisciplinary team and care coordination. The position is a system super user and is involved with training and oversight of the new hires and ongoing staff. The Clinical Nurse Supervisor, as part of the leadership team, facilitates relationships in the community with providers, health plans, vendors, facilities and community organizations.
- Provide operational support for the Health Services Director and Market Leadership team
- Interface/collaborate with contracted health plan contacts on patients referred to Landmark programs.
- Assist with strategy and process development, and implementation, including measurement of outcomes
- Verify eligibility for Landmark program referrals, community referrals as well as internal referrals through review of cohort lists and collaboration with health plan contacts
- Outreach and follow cohort patients admitted to hospitals for admission to Landmark programs and facilitate post discharge follow-up
- Discuss with patient, family and extended decision makers the benefits of participation with Landmark programs post hospitalization
- Open case management cases in Essette for case management referrals; and assigns cases to NCMS and providers based on assigned territory
- Attend and actively participate in contracted health plan IDT, Clinical Operations, JOC’s and other operational meetings as required
- Act as super-user and trainer for Essette, and CRM and other systems
- Working with the corporate Operations team, assures documentation is completed by providers and reported up to HSD
- Visit patients in hospital/SAR who are not yet enrolled and those that are to assure a smooth transition home
- Monitor Daily Pulse Report and other performance and operational reporting to take appropriate action based on the data
- Schedule Urgent visits for providers from on-call and during business hours, including juggling the schedules
- Triage phone calls that come into office to ensure appropriate disposition and action
- Triage and take appropriate action regarding warm transfer calls from Outreach
- Maintain health plan referral Logs
- Maintain patient Hospitalized/SAR log book and/or electronic tracking systems
- Maintain weekly IDT Stat Sheet, minutes, sign in sheets and log book
- Lead weekly IDT meetings
- Email daily the list of new patients to provider and NCM
- Actively involved with training of new NCMs and Providers
- Support and execute corporate initiatives
- Reconcile provider’s schedules and make appropriate corrections
- Open new cases in Essette for NCMs
- Meet with families in facilities and at home as needed to discuss Landmark programs
- Represent Landmark at provider, vendor, facility and health plan meetings as assigned/requested
- Collaborate with Office Manager for provider and NCM medical supply needs
- Oversee the CMA process for scheduling of maintenance visits using the maintenance tracker report
- Maintain staff PTO calendar
- Maintain On call schedules/calendars for Providers and NCM's
- Collaborate with SAR/ALF facilities for appointment dates for post discharge and updates for those already enrolled.
- Maintain Provider schedules for meetings, PTO etc.
- Maintain quality of services through audits and education
- Participate in and lead CQI teams
- Serve as a resource to the entire care delivery team
- Identification, tracking, resolving, responding to and reporting any quality of care issues
- Maintain HIPAA compliance as it relates to member care
- Participate in interviewing, hiring training, evaluating and disciplining of IDT staff
- Other duties as assigned
- Current RN License, BSN preferred
- 5+ years of clinical practice in a hospital, clinic, home care, or nursing home setting
- 2-3 years of increasing supervisory or management experience in a health care setting
- Case management experience required
- Disease and utilization management experience useful
- Physician office experience helpful
In order to work with potentially vulnerable patient populations and to keep employees healthy while caring for patients, all patient-facing employees of Landmark must provide evidence of the following required immunizations/vaccinations as a condition of employment: TB, MMR, Tdap, and Influenza. Declinations may be accommodated based on your medical history, an allergy or religious beliefs. Please immediately contact HR if you wish to apply for an exemption from our vaccination requirements so that we may determine if you qualify for an accommodation.