Quick overview
Job description
Job Summary
This role supports care management activities and value-based care initiatives for ambulatory services, specifically within the medical group. Performs all duties as assigned.
Job Responsibilities
· Collaborate and participate in Baptist Medical Group’s care management and value-based care initiatives.
· Provide education to patients and caregivers regarding self-management of health care conditions that are appropriate based on language, cognitive abilities, literacy levels, patient preferences, and readiness for change.
· Facilitate the transition of patient care from inpatient settings such as hospitals, rehabilitation facilities, and skilled nursing facilities back to the patient’s home or community setting.
· Develop a comprehensive, collaborative care plan, based on the provider’s treatment plan.
· Assist patients with care coordination needs, including provider referrals, medication refills, appointments, and preventive screenings, as appropriate.
· Promote patient adherence to provider recommendations and treatment plan.
· Collaborate with providers to strengthen clinical documentation and support risk adjustment initiatives.
Experience:
Minimum Required
· 3 years of nursing experience on current unit or in specialty area.
Preferred/Desired
· Experience with care coordination, case management, or utilization review processes.
Education:
Minimum Required
· BSN or equivalent years of nursing experience
Special Skills:
Minimum Required
Strong analytical and data management skills. Comfortable seeking direction and assistance from appropriate resources. Ability to communicate effectively verbally and in writing. Proficient ability to use a computer and electronic medical record. Comply with all
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