Hybrid RN Case Manager

Position Summary

Manages targeted patient populations to achieve efficient and effective care delivery. This includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Coordinates with the Primary Care Physician (PCP) and functions as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care settings. Ensures continuity of care through defined, evidence-based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care giver, health education and referrals.

Collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources.

AHI agilon health, inc.

Miamisburg, OH

Hybrid RN Case Manager

Manages targeted patient populations to achieve efficient and effective care delivery. This includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Coordinates with the Primary Care Physician (PCP) and functions as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care settings. Ensures continuity of care through defined, evidence-based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care giver, health education and referrals.

Collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources.

Splits time working in our Dayton, Ohio office and remotely from home. Individual must be based in the Dayton area.

Facilitation of Patient Centered Care

• Identifies, evaluates, engages and enrolls high risk patients of specified populations
• Performs complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources
• Based on assessment and in conjunction with patient/family/caregiver, provider, and other healthcare team members, participates in the development of an initial Plan of Care and Self-Management Plan that highlight actual and potential opportunities for improving clinical outcomes and/or utilization patterns and decreasing gaps in care
• Facilitates and monitors implementation of Plan of Care
• Coordinates patient/family/caregiver participation in Plan of Care and self management
• Uses knowledge of community resources to facilitate achievement of goals
• Coordinates patient education to achieve Plan of Care using evidence- based methods such as teach back
• Performs home visits as necessary to evaluate possible barriers to attainment of self management goals and develops strategies to overcome barriers
• Other duties as assigned

• Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post acute and home settings
• Demonstrates expertise in case management and serves as resource to the interdisciplinary health care team
• Integrates knowledge of external and internal regulatory requirements into the review and management of cases
• Works in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care
• Serves as bridge across the clinical setting and functions as patient's consistent point of contact
• Facilitates referrals to other disciplines and internal health and community based programs as appropriate to improve patient outcomes

• Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-Process Metrics, NCQA, URAC and HEDIS) when coordinating and facilitating Plan of Care
• Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice

• Documents in the medical record as indicated and designated case management tool…