SUMMARY
Coordinate care for the patients of the Population Health Management department and MMC with disease specific plans of care, developed in conjunction with the patient.
JOB DUTIES
Ensures timely communication with patients, significant others, and other healthcare providers through professional collaboration.
Collaborates with other health care providers to deliver patient-centered care in a manner consistent with safe, efficient and cost-effective resource utilization.
Assists with identification and alignment of community resources with patients.
Plans integration of care with all appropriate providers.
Discusses progress of patients with Pop Health core team.
Works collaboratively with the Meadville Medical Center to integrate service delivery system for co-morbidity/co-occurring treatment.
Works in collaboration with MMC, subsidiaries, and external collaborating agencies/groups to develop a system of continuity of care.
Documentation on chart is timely and appropriate.
Assists with community outreach educational programs in correlation with chronic disease management.
Provides individual and/or family support.
Physical, psychological and emotional outcomes are individualized.
The plan of care is consistent with safe, effective patient care and age. Physical, psychological and emotional outcomes are individualized.
The urgency of psychological, social and emotional needs is determined, and the course of action is formulated to attain expected outcomes.
Outcomes are assessed on a regular basis to measure improvements/deficits.
Evaluates and modifies plan of care based on patient responses and attainment of expected outcomes.
The patient’s response to the intervention is regularly evaluated to determine progress toward resolution of needs.
Adheres to established standards of practice including activities and behavior that characterize professional status. Is aware and maintains current understanding of CMS initiatives.
Serves as member of interdisciplinary team to assist with program development.
Develops, implements, and evaluates goals in collaboration with team of clinicians, providing quarterly reports of progress to Pop Health Management. Participated in Annual Wellness Visit completion and development of preventative plans of care with patients and their PCP.
Performs other duties as assigned.
SPECIFIC JOB DEMANDS
Strength: Sedentary Work - Lifting, Carrying, Pushing, Pulling 10 Lbs. occasionally. Mostly sitting, may involve standing or walking for brief periods of time.
Reaching: Occasionally - Extending hand(s) or arm(s) in any direction.
Handling: Occasionally - Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand.
Fingering: Occasionally - Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm as in handling.
Talking: Frequently - Expressing or exchanging ideas by means of the spoken word to impart oral information to clients or to the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly.
Hearing: Frequently - Perceiving the nature of sounds by ear.
Near Acuity: Frequently - Clarity of vision at 20 inches or less.
MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED
Minimum ASN or BSN education required.
Minimum of 3-5 years of nursing experience. Care Management experience preferred.
ACLS Certification as well as Critical Care and Cardiac Skills required. Maintains an appropriate and current state license.
Professional knowledge of integrative medicine and current research within field.
Skills necessary to effectively communicate with various members of the health care team, other health care facilities, community health related organizations, various external parties and regulatory agencies.
Ability to concentrate and prioritize, resolve problems, and interact with situations. Must be able to remember, reason, understand and be emotionally stable.
Able to work as a team member.
Ability to supervise and manage intern(s). Must be willing to use the following management accountabilities and competencies: conflict resolution, staff counseling, problem solving, disciplinary process, policy and procedures implementation, teamwork, staff scheduling, interviewing, budgeting process, cost containment skills and support of peers.
WORKING CONDITIONS
Normal office environment with little exposure to excessive noise, dust and temperature changes. A large part of work is sitting or walking. Stress is a large factor in environment.
Work week may exceed 40 hours and hours may vary depending on needs.
Travel to various health related or business locations within county may be necessary.
Expected to perform an initial evaluation in one hour and a follow-up in 45 to 50 minutes, on average.
DISCLOSURE
MMC commits to review, under the intent of this standard, and in coordination with medical professional opinion’s and physical demands job analysis performed by certified professionals, an individual’s ability to be reasonably accommodated within the role they are responsible and qualified to perform.
MMC is committed to complying with the Americans with Disabilities Act (“ADA”) and providing equal opportunity employment for qualified persons with disabilities. All employment practices and activities are conducted on a nondiscriminatory basis. Meadville Medical Center will follow any state or local law that provides individuals with disabilities greater protection that the ADA.
Every effort has been made to make your job description as complete as possible. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific tasks does not exclude them from the position if the task is similar, related, or is a logical assignment to the position, or is imperative for patient care and to meet emergency situations.
