Cape Fear Family Medical Care is searching for a Transition of Care RMA / LPN / RN to join their team. We're an independent physician practice located in Fayetteville, North Carolina.

The Transition of Care RMA / LPN / RN tracks patients who are discharged from the hospital and offers ongoing care coordination. This transitional care includes medication reconciliation, disease management and education and discusses ED / hospitalization encounters with patients to improve outcomes.

JOB DUTIES

• Works with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient’s unique social and cultural dynamics
• Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by identifying, arranging, and coordinating physical and/or behavioral health care services in concert with the PCP
• Collaborate with network providers in assuring appropriate client management
• Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
• Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with healthcare team
• Maintain appropriate client documentation in the EHR
• Develop and implement individualized care management plans for identified clients
• Provide direct follow-up and outreach services via face to face encounter (home visit, provider office visit, or community encounter), phone or mail
• Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
• Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
• Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
• Act as a liaison to providers to ensure the use of Evidence Based Practices
• Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
• Coordinate, develop and provide health care education programs and trainings
• Advocate for patients to receive services that will improve their health condition
• Assess patients’ plans of care for any duplicate or unnecessary services to control costs to payor
• Audit charts and compile data to support the disease centered initiatives
• Responsible for maintaining patient and family confidentiality in accordance with HIPAA
• Other job duties as required

QUALIFICATIONS

• Degree in RMA or Nursing (RN or LPN)
• Experience in direct patient care / managed care is highly preferred
• Must possess a valid driver’s license
• Personal vehicle is required for travel between work sites
• HEDIS Quality Measures experience
• Excellent communication and customer service skills required Proficiency in Word, Excel, and PowerPoint required.
• Ability to work independently, while collaborating with other team members
• Ability to self-motivate, prioritize, and be willing to invest in a change process to improve efficiencies