The CCDM ensures that program objectives are met and supports patients and physician practices in coordinating patient care through transitions. (Transitions may include but are not limited to discharge from hospital or skilled nursing facility, enrollment in palliative care or hospice services, and/or post emergency room visits). This role additionally connects high risk, “most vulnerable” patients to programs and services as available through PHM and within the community. This position manages a panel of patients coordinating services with them. This role provides disease management and ongoing follow up of members with Congestive Heart Failure, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. (Other conditions may be identified based on patient need.)
- Internal and External Relationships: Identify and build effective relationships with a network of community, government, medical group, health plan resources. Establish and maintain a professional, collaborative positive relationship with the patient, family, physician(s), and other providers to assess the options for care and use of benefits and community resources.
- Act as liaison between Practice Offices regarding specialty Prior Authorization requests.
- Educate matrix partners in regards to PHM programs
Care Coordination: Coordinates the care of the high-risk, post transition and targeted populations in appropriate, efficient and cost-effective manner.
- Assists patient to arrange timely access to services, evaluates social/financial/environmental support adequacy in a culturally sensitive manner.
- Documentation: Maintains appropriate documentation and tracking as required by Cigna and the PHM Department.
- Disease management/outreach: Initiate new customer and ongoing telephonic connections per protocol for an identified caseload. Build care relationships among patient/SO. Completes a ‘post discharge’ call to all identified patients to facilitate and oversee discharge planning “coordination of care” needs identifying and closing gaps in care with in specified timeframes. Following department protocols, establishes sick day plans and educates patients on needed self-care elements.
Other duties: Represent PHM department as a member of a cross-functional project team. Other duties as assigned.
- Clinical Knowledge: Maintains current knowledge base on the critical elements of the target population such as disease states, quality standards, utilization patterns, clinical treatment guidelines. Targeted disease states include but are not limited to COPD, CHF, DM, depression.
- Coordinates and identifies high-risk population with a history of poly-pharmacy, to improve quality outcomes with appropriate support services in managing pharmacy needs.
- Current AZ LPN License required
- Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly,
- Computer skills in Word and Excel with demonstrated ability to learn scheduling and documentation in Patient Management and E.H.R programs.
- Excellent oral and written communication skills,
- Demonstrate commitment to ongoing education.
Qualification & Experience:
- 1-2 years nursing experience in preferred
- Experience in cardiac/pulmonary/diabetes nursing preferred
- Care Coordination/Disease Management experience preferred
Vacancy Type: Full Time
Job Functions: Health Care Provider
Job Location: America, OK, US
Application Deadline: N/A