Care Manager - Usftgp Umsa Quality And Safety

The Care Manager assists high-risk patients across the continuum of care; serves as a primary point of contact for these patients' providers across care settings; aims to better manage high risk patients in the primary care ambulatory setting by assessing care gaps in preventive and chronic conditions and prevent acute care and ED use through the implementation of a multidisciplinary plan of care. This individual will work closely with USFTGP's primary care physician offices to optimize quality, risk adjustment and general population health management.

Essential Functions:

• Partners with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness
• Provides effective clinical health coaching to assist patients with self-management of their chronic disease and lifestyle changes as well as assess social determinants of health to mitigate health risk & enhance health outcomes
• Assess high risk patients through the performance of annual wellness visit/chronic care management, determine gaps of care, reduce readmits and/or care in acute setting (e.g. ED) and refer to ancillary & community providers to ensure continuity of care
• Have knowledge of risk adjustment coding and stratify patient population according to risk to effectively & efficiently manage patients
• Responsible for transitioning services & coordinating services of care while providing highest level of customer service • Collaborates with the Accountable Care Organization (ACO), Clinically Integrated Network (CIN) and Managed Care staff/payer partners to optimize success under new payment and care models that seek payor partnerships and incentives that align with USFTGP goals of improving the overall health of our patient population
• Responsible for independently meeting productivity expectations
• Is proficient in behavioral interviewing in order to use active listening skills and verbal persuasiveness in order to easily understand the concerns of the patients and their families, influence their attitudes and explain treatment regimens in an accessible way to reduce resistance.
• Ability to function autonomously while keeping team members and leaders informed
• Ability to work remotely in a professional environment free of distractions and available for in person Annual Wellness Visits (AWVs) and in person meetings as needed.
• Strong writing, interpersonal communications and organizational skills is required.
• Experience with Epic, Cerner or other EHR software systems a plus.
• The Care Manager is a problem-solver, has good communication skills, and works effectively with multiple customers including patients, members of the care team, and payors. Embraces the role of a variety of professional staff and their ability to contribute to improvement.
• Successful completion of an RN program
• Bachelor of Science in Nursing (BSN) or Associate of Science in Nursing (ASN) with 3-5 years of experience in an ambulatory or community setting
• Active Florida Registered Nurse License
• Ambulatory Care Nursing/Care Coordination & Transition/Management Cert/Telehealth Nursing Cert/ or Case Management Cert- Preferred
• 2-5 years' experience in healthcare setting. If ASN, 3-5 years of experience in an ambulatory or community setting
• Chronic care/case management experience- Preferred