222822 General Summary Coordinates and monitors the health needs of patients under value-based care risk arrangements, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. This position works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient's maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. This position ensures patient's cases are in compliance with regulatory guidelines.

Responsibilities

Duties and Responsibilities Remote Work Capable

• Utilizes Motivational Interviewing as a patient-centered technique to promote self-management of chronic conditions and improve long-term outcomes.
• Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols.
• Engages patients in home, primary care offices, and other community settings as appropriate.
• Identifies, enrolls, and manages patients in Complex Care Management programs.
• Conducts Transitions of Care and proactive outreach for high-risk patients and ensures appropriate follow-up via care management, or technology.
• Develops, implements, and updates individualized care plans to optimize health outcomes and promote wellness.
• Performs medication review and uses teach-back methods to confirm patient understanding and adherence.
• Collaborates with PCPs, specialists, and hospitalists to coordinate and implement patient-centered care plans.
• Initiates and tracks referrals to internal services and community resources to support care goals.
• Provides resource management to ensure the right care is delivered at the right time and place, optimizing cost and experience.
• Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care.
• Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards.
• Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Attends meetings as required.
• Performs other related duties as identified.
• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. Travel Requirements:

• Estimated Amount: 10% - Travel required. Makes home visits.

Qualifications

Qualifications Minimum Education:

• Associates Degree Required
• Bachelors Degree Preferred

Work Experience:

• 3 years Nursing experience. Required
• Experience in Care Management or Clinical Nursing specialty. Preferred

Licenses:

• Licensed Registered Nurse Upon Hire Required or
• Registered Nurse Multi State License Upon Hire Required and
• Basic Life Support Upon Hire Required

Courses and Training:

• Residency in service area. Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Excellent communication and interpersonal skills.
• Proficient in SBAR technique.
• Ability to effectively present clinical information to the care team.
• Proven organizational and motivational skills.
• Ability to work cooperatively as part of a team.
• Self-motivated and dependable.
• Able to work independently.