Summary
Works collaboratively with the Field Health Staff and other Funds’ staff to coordinate and integrate Funds’ health programs, initiatives, and activities in the field. Works directly with beneficiaries in their homes through the clinical process of assessment to coordinate the delivery of health services to improve beneficiaries’ health, well-being, and quality of life. Collaborates and maintains close working relationships with providers and community agencies to promote beneficiary welfare and health education in their homes or in the community. Promotes beneficiary access and participation in health promotion, disease prevention, and health education programs. Develops and implements innovative programs that will assist beneficiaries in their health and daily living and support the principles of the Funds.
Essential Duties and Responsibilities include the following. Other duties may be assigned:
Serve in a nursing capacity and work with Funds’ staff on clinical, public health, care coordination, health service delivery, and geriatric issues, as well as on those Field Health activities that relate to GCM and/or other Funds’ programs. Gather information and assist in problem solving for difficult beneficiary issues identified by senior management or the Funds staff.
Organizes and implements beneficiary outreach programs to frail and remote beneficiaries, their families, their caregivers, and/or other specific beneficiary target groups. Collects and documents beneficiary health information utilizing the Funds’ General Health Assessment and/or other relevant assessments. Identifies and addresses beneficiary risk factors and/or obstacles to care. Identifies beneficiary needs, current services, and available resources. Provides information and referrals for appropriate resources within the Funds and/or within the community. Communicates the care preferences of beneficiaries serving as their advocate and verifying that interventions meet the beneficiary’s needs and goals. Educating the beneficiary/family/caregiver about Funds’ benefits, healthcare, and healthy lifestyle changes through written, verbal, and demonstration of educational techniques.
Reviews medications, current health conditions, and health concerns and provides education to assist in better overall understanding. Works to empower beneficiaries and families to speak with their doctors about their needs, concerns, and or health goals.
Participates in continuing education for ongoing learning. Stays current on advances in healthcare and trends and conducts appropriate research to provide credible, relevant, and up to date information.
Serves as a resource for beneficiaries and families in providing information on disease process, treatment options, medical professionals, and health care facilities.
Collaborates with the Funds medical management vendor through referrals and follow up to assess beneficiaries’ health status, without providing any direct “hands on” nursing care. Provides valuable clinical information from observation and dialogue with beneficiaries and caregivers to assist in care coordination. Coordinates and recommends intervention by the appropriate agency or provider if direct nursing care is needed by the beneficiary to support the most appropriate plan of care. Assesses beneficiaries for appropriate DME needs in the home and follow the established policy to facilitate placement of equipment and supplies.
Collaborates with the Senior Managers of Health Operations and Eligibility Services and with the Funds’ medical management vendor to monitor, manage, and improve the Funds’ care coordination programs and assure appropriate and effective care coordination programs and activities.
Enters and maintains assessments, authorizations, and pertinent clinical information in medical management systems. Maintains beneficiary’s health records by reviewing case notes, documenting events and progress, and communicating relevant case information to care coordination staff.
Collaborates with Senior Managers, Community Health Nursing, the Director, Network Development and Provider Relations, the Senior Manager, Claims Administration and Beneficiary Relations, the Call Center Manager and the Central Office Program Managers to create and implement health education and wellness promotion programs for Funds’ beneficiaries. Assists in researching and finding potential vendors or providers to aid in providing transportation, health services, and/or other of Funds’ benefits when new providers are needed.
Identifies health care issues that affect beneficiaries and collaborates with physicians, community agency heads, and health care executives to implement interventions that will enhance, maintain or restore health, prevent disease, and maintain beneficiary independence.
Identifies beneficiaries with complex medical issues and needs. Collaborates with Field Health Management for coordinating of a case conference to identify interventions that will assist beneficiary in obtaining appropriate resources, empower beneficiary to manage diseases process, and maintain beneficiary independence.
May develop/conduct health education programs that encourage and empower beneficiaries to make healthy but difficult lifestyle changes, to be motivated to be healthier, and to actively participate in the management of their health conditions through education and communication with physicians.
May investigate, assess, and recommend local community-based health education and disease prevention programs if they meet the health care needs of beneficiaries.
Promotes beneficiary access and motivates beneficiary participation in health promotion programs which foster behaviors that maximize wellness minimize the development of disease.
Makes available and recruits for participation in ongoing health education, wellness, and care coordination programs.
May complete leader training in evidence-based programs when appropriate. Offers such programs and actively recruits beneficiaries to enroll and participate in them.
Conducts program evaluations with beneficiaries to obtain health outcomes using Funds’ approved standardized measurements.
Identifies and recommends health and wellness written communications for beneficiaries.
Prepares written reports and/or oral presentations to trustees and/or other operations staff on the status of the activities in the field service office.
Teaches appropriate health maintenance skills to beneficiaries, family members, and caregivers through written, verbal, and demonstrative educational techniques. Has the ability to work with older adults primarily in rural settings in a non-judgmental manner.
Provides healthcare consultation to beneficiaries and families where appropriate.
Can function in a professional manner in stressful and/or uncomfortable situations.
Provides clinical review support for the medical record review portion of the Medicare audit.
Responsible for adhering to all Funds’ policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information.
SUPERVISORY RESPONSIBILITIES
This position has no supervisory responsibilities.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Must be willing to travel, with some overnight travel required. Must be willing to work independently as well as in a team. Must be willing to work flexible hours in a non-structured environment. Must be able to manage multiple priorities and handle competing demands in an effective manner. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Bachelor's degree in Nursing(BSN) or equivalent plus four to six years related experience and/or training; or equivalent combination of education and experience.
COMMUNICATION SKILLS
Requires excellent oral communication skills to effectively work with beneficiaries, their family members and care givers, to motivate, encourage and persuade them to make substantial changes in lifestyle and behavior. Must be an empathetic and active listener. Must also be able to communicate effectively with other Field Office staff, providers and community hospital executives and heads of agencies.
CERTIFICATES, LICENSES, REGISTRATIONS
Maintains an active RN License for all states covered by the position. Adheres to the Nurse Practice Act and the Standards of Nursing Care.
Maintains a current CPR - Basic Cardiac Life Support Certification. Meets professional and personnel requirements (e.g. license renewal, CEU requirements for licensure).
PHYSICAL DEMANDS
The physical demands described here are representative of those that are typically experienced by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to handle or feel objects, tools, or controls and reach with hands and arms. The employee is occasionally required to walk; climb or balance; and be able to bend, stoop, and crouch. Specific vision abilities required by this job include close vision, distance vision, color vision, and the ability to adjust focus. Must have reliable transportation, be able to legally drive an automobile, and be willing to travel a minimum of 60% of the time. May occasionally be required to lift and move objects weighing up to 20 lbs.
COMPLETE BACKGROUND CHECK REQUIRED.