Personal Health Nurse - Remote

Job Summary JOB SUMMARY CCCS uses a holistic approach to medical management. The Personal Health Nurse (PHN) works within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost-effective means. The PHN performs the Personal Health Management process: assess the member; work with the member, family and physician to identify problems; establish goals and develop plans of care; coordinate services; educate members; and empower members to independently self-manage and to make knowledgeable health care decisions. The PHN works closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s) by performing functions of Personal Health Management as well as some functions of Utilization Management. Additionally, the PHN interfaces with clients and with CCCS client managers and are responsible for the medical management of designated client(s). All Medical Management Nurses practice within the scope of their licensures. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Manages accounts using the 4-Prong approach, meeting expected number of billable hours and using Conifer Value Based Care tools ( CCOO) according to standard protocol. Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity Reviews daily calendar for new episodes and tasks due, prioritizes tasks on calendar Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the member and the physician’s assessment and treatment plan Determines and documents member’s goals, engages the member in the personal health management process. Develops an ongoing individualized plan of care with timeframes, reasonable and appropriate expected outcomes, specific planned interventions and member’s goals. Follows through with interventions and documents outcomes in Current Clinical Status section of care plan Engages the PCP and treating physicians in the personal health management process, Collaborates with the member and PCP in development of an individualized plan of care Closes episodes as indicated, i.e. evaluates “Impactability” among other indications for closure. KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Understanding of CCCS holistic approach to medical management Understanding of the client’s (customer’s) perspective and needs Understanding of legislative acts, such as the ADA Competency in Word Competency using email, attachments Excellent verbal communication skills with the ability to communicate with members and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, client managers, customer service staff, CCCS executive management, oth