VIVA Careers / Careers @ VIVA /

Care Management Nurse - Health Awareness Program for TKC Medical Home

Job Description | Triton Health Systems, LLC.

Date Prepared:	6/15/2010 12:00:00 AM	Reports To:	Director of Medical Management
Manager Approval:		Department:	Medical Management
HR Review:		Status:	Exempt
Employee Signature:		Revisions:

Job Summary Responsible for performing discharge planning and care management of selected members. This includes an initial member assessment, development of a care plan, periodic follow-up and tracking of key indicators. The Care Manager helps members understand their medical condition(s) and facilitates access to appropriate medical and social services. The primary goal of VIVA’s care management (HAP) program is to provide members the information and tools needed to better manage their conditions. The Care Manager assesses progress against the member’s care management plan and goals and adjusts the plan and goals as needed. The care manager will also act as a liaison among patients, Medical Home physicians and other health services.

Essential Functions

Activities: • Assists in the development and continuous improvement of VIVA’s care management program (HAP) and related interventions, tools, and policies and procedures. • Identifies members for the care management program based on the program’s specifications. • Educates members and providers on the care management programs and accepts and investigates referrals to the program from appropriate sources. • Conducts initial assessment of care management members including completion of the care management program’s health assessment questionnaire and review of other information specified in the program such as pharmacy data, claims data, and lab values. • Develops member specific care management plans based on results of the initial assessment.
Activities: • Conducts interventions to assist members in meeting the goals of their care management plans. Interventions will very by care management program and by member and may include mailings, telephone calls and home visits to the member. • Initiates referrals to social services or other programs. • Enters all information for the care management program into PowerSTEPP. • Monitors effectiveness of the care management program overall and on a member-specific basis using information collected. • Implements program improvements based on the overall program assessment and revises the member specific care plans as needed based on individual progress.
Kirklin Patient Centered Medical Home: • Works with the Kirklin Patient Centered Medical Home (KPCMH), including spending the appropriate amount of time in the medical home office. • Collaborates with KPCMH physicians and advanced practice nurses in the development and implementation of care plans • Provides, as needed, follow-up phone contact with recently discharged patients to assure home needs have been met, answer questions, and assist with problem resolution as needed.
General: • Develops and maintains a good working relationship with VIVA Health providers, social service agencies and other organizations, members, and their families and caretakers. • Maintains a professional approach with confidentiality issues. • Cooperates and works positively with employees of all levels within and outside of department. • Meets department criteria and performance standards. • Develops and maintains positive image of Triton and VIVA Health, both internally and externally. • Keeps Manager, Director and Medical Director informed with the performance of the program.
Standards of Performance: • Meeting all CMS and VIVA requirements for care management programs. • Conducting required assessments and interventions within timeframes specified and recording all results in PowerSTEPP. • Meeting improvement goals and adjusting care management programs when goals are not met. • Maintains current licenses and training as required for this position.

Qualifications • Licensed Registered Nurse or LCSW in good standing with the State of Alabama. • 5 years clinical experience • Must be able to transport self to area agencies and meetings if needed. • Past experience in disease management, home health, case management, and/or utilization review required. • Knowledge of community resources, Medicare, and Medicaid regulations preferred. • Excellent verbal communication skills. • Good computer data entry skills. • Reliable means of transportation and automobile insurance as required by the State of Alabama.

Physical Qualifications • Must be able to work under pressure from deadlines and goals. • Must be able to spend a large part of the day sitting at cube, desk or table. • Requires repetitive wrist, hand or finger movement • Occasional lifting (>25 lbs) • Must have reliable means of transportation and be able to drive to remote areas

Additional Responsibilities Other duties as assigned. The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties, and tasks required of the individual as classified.