At York Hospital, we're more than a hospital. We are a team of providers, clinicians and staff members offering expertise within a Hospital setting, our community sites, and physician practices located throughout Southern Maine and the NH seacoast. Our caregivers' commitment is to make a positive difference in the lives of one another, our patients and our community by instilling our vision of Loving Kindness for all.
York Hospital, we are a Community. For Life.
We currently have an opportunity for an experienced RN Care Manager. This is a full time, 40hrs/wk opening in Care Management and is located in York, Maine
This position will be responsible for facilitating communication between the patient, their primary care physician and specialists to improve clinical outcomes.
· Works collaboratively with the patient to foster self-management and compliance to their clinical plan of care.
· Works collaboratively with physician, hospital and community resources to support the patient's clinical plan of care.
· Understands the Patient Centered Medical Home model of care. Assist with developing practice policies that meet NCQA Patient Centered Medical Home standards and YH strategic objectives.
· Assist in creating and maintaining care management systems to prospectively identify and track patients with chronic disease, or who are at risk to chronic disease; and/or patients with diagnoses that put them at high risk for hospital admission as well as promote overall population health management.
· Proactively participates in a centralized care management delivery model to provide protocol-driven care transition support and follow up to patients across York Hospital locations. Proactively manages care transition of patients to and from the ED, hospital, and other institutions.
· Attests to the maximum number of MaineCare patients on the Health Home portal on a monthly basis. Utilize Anthem and other population health portals as appropriate to coordinate care.
· Coordinates care management with the contracted MaineCare Community Care Team and represent the practice at Integrated Care Management meetings.
· Works with the practice team to develop care plans using protocol-driven care management.
· Proactively engage patients in their care with strategies to improve self-management. Provides patient/family/caregiver education and act as patient advocate in the delivery and coordination of patient care.
· Demonstrates high level clinical care skills, familiarity with preventative care guidelines and standards throughout the lifecycle.
· Organizes and provides staff education to address identified needs, elevating support staff roles to highest level of licensure within a team based model of care delivery.
· Provides proficient telephone nursing triage and customer service acting as a liaison between patients and the practice team to provide exceptional patient experiences. Organize care and multitask as a forward-thinker, while remaining calm and personable in a fast paced office setting.
In order to help us continue to provide exceptional patient/customer experiences, we need candidates with the following:
· State of ME, NH or Compact RN License
· 1-2 years of Care Management experience
· Detail oriented and process focused