Summary
Job Summary

Oversees care management and coordination of activities for patients of the healthcare system. Develops and monitors care management coordination processes and support of patients for multidisciplinary teams. Identifies high acuity patient population, high utilizers, and high readmission risk patients.
Job Responsibilities

• Works with all clinical teams as a resource on care management of all patients of the healthcare system to ensure care completion in and out of the hospital setting.
• Involves the patients in activities to improve their health (patient engagement); educates patients about self management tasks they can undertake to gain greater control of their health status.
• Manages assigned panel of chronic care, high acuity, and readmission risk patients.
• Develops relationship with patient as an integral member of the team.
• Provides follow-up contact with patient as indicated to ensure compliance with recommendations, medications, lab, x-ray, specialist visits, Primary Care Physicians (PCP) visits, dietitians, and durable medical equipment (DME), etc.
• Manages many aspects of the patient's care: referral to specialists, hospitalizations, emergency department (ED) visits, ancillary testing, nd other enabling services.
• Makes home/community visits when deemed applicable to assist with social determinants of care and resolution to social barriers.
• Available to provide telephone advice per protocol, handles urgent and emergent calls.
• Anticipates the needs of this patient population seeing that necessary documentation and planning is completed for patient continuity of care.
• Works with patient and patient's care team to coordinate change readiness, needs assessment, and develops an individualized treatment care plan.
• Assists patient in setting SMART goals for self-management, teaches them how to do self-management tasks, and reports abnormal finding to their physician team.
• Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward health care goals.
• Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
• Oversees the development, procurement, and adoption of patient self-management educational resources used by the clinical teams.
• Collaborates with payer care managers for additional services when appropriate.
• Develops a list of medical supplies and community resources available to patients and maintains collegial relationships with the entities used most frequently.
• Works with consulting physicians, hospitals, ED, and other frequently used healthcare sources to clarify roles and develop effective, efficient, and timely communication between PCPs and these entities.
• Coordinates consults, referrals, hospital/ED, and community resource follow-up and tracking processes for the health system working to have clerical component done by appropriate clerical staff.
• Develops workflows and protocols within the healthcare system that ensure the ED, hospital, and community resource follow-up.
• Facilitates clinical follow-up with patients when indicated.

Qualifications

• Associate's degree or higher or Diploma in Social Work required upon hire AND
• Bachelor's degree or Master's degree in Nursing required within 5 years of employment in this position OR
• Bachelor's degree or higher in Social Work required upon hire
• No experience required
• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the States of Kentucky required upon hire OR
• LSW - Licensed Social Worker in the State of Kentucky required upon hire OR
• LCSW - Licensed Clinical Social Worker in the State of Kentucky required upon hire OR
• CSW - Certified Social Worker in the State of Kentucky required upon hire AND
• Driver - Valid driver's license and 21 years of age required upon hire

Skills and Attributes

• Requires critical thinking skills and decisive judgment.
• Works under minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Physical Demands

• Standing: Occasionally
• Walking: Occasionally
• Sitting: Frequently
• Lifting 0-25 lbs: Rarely
• Lifting 25-75 lbs: Never
• Lifting over 75 lbs: Never
• Carrying 0-25 lbs: Rarely
• Carrying 25-75 lbs: Never
• Carrying over 75 lbs: Never
• Pushing/Pulling 0-25 lbs: Rarely
• Pushing/Pulling 25-75 lbs: Never
• Pushing/Pulling over 75 lbs: Never
• Climbing: Rarely
• Bending/Stooping: Rarely
• Kneeling: Rarely
• Crouching/Crawling: Rarely
• Reaching: Occasionally
• Talking: Frequently
• Hearing: Occasionally
• Repetitive Foot/Leg Movements: Never
• Repetitive Hand/Arm Movements: Frequently
• Keyboard Data Entry: Frequently
• Running: Never
• Vision: Depth Perception: Frequently
• Vision: Distinguish Color: Frequently
• Vision: Seeing Far: Frequently
• Vision: Seeing Near: Frequently

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.