Value-Based Care Manager (RN) - Full Time Wolf River

Summary:

Responsible for the health care management of oncology patients participating in value-based care programs.  Works with the patients and caregivers by matching patient needs with appropriate services, maintaining and updating patient records, reviewing clinical diagnoses and treatments, and ensuring compliance with the required practice redesign elements.  Models appropriate behavior as exemplified in the Mission, Vision and Values of WCCRI.

Education/Training & Experience:

Knowledge/Skills/Abilities:

• Knowledgeable of health care management resources in order to match patient needs with appropriate services.
• Must have excellent verbal and written communication skills, a desire to problem solve, and strong conflict resolution abilities.
• Proficient in the use of Microsoft applications (such as Word, Excel), security measures, and legislation regarding patient privacy.
• Ability to communicate verbally with all levels of employees, physicians, patients and families.
• Ability to work without close supervision and to exercise independent judgment.
• Ability to organize multiple tasks and projects and maintains control of workflow.

Key Job Responsibilities:

• Serves as a central point of contact, thereby eliminating redundancy, to effectively manage patients at high risk for complications.
• Employs a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocating for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.
• Works collaboratively with the patient’s primary team, especially the nurse navigator, to ensure coordination of care without overlap or redundancy.
• Decrease healthcare barriers by assessing the needs of patients, families, and caregivers and providing anticipatory guidance and education.
• Provides appropriate clinical actions within the scope of nursing practice and clinical training.
• Informs patients regarding general preventative care practices as well as reinforces individualized care plans to prevent unnecessary admissions, readmissions, and over-utilization of resources.
• Tracks patients' progress and outcomes; adjusts plans as needed in collaboration with the oncologist. Schedules appointments with the patients, converses with physicians and specialists, contacts outside agencies and companies for their patients, and/or arranges other services that will enhance the patient’s care and well-being.
• Assists patients in managing their health conditions, prioritize their healthcare needs; prevent complications through standardized care protocols, and the healthcare system.
• Assists with the transition of care for patients who are discharged from the hospital, ensuring a seamless transition back to the outpatient setting, management of discharge medications, and scheduling of follow-up appointments.
• Works with the provider clinic staff to ensure that staging and other pertinent clinical information including oncology/hematology diagnoses and other medical problems are documented.

Supervision Provided by this Position:

• There are no supervisory roles assigned to this position.

Physical Demands/Conditions:

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: medium work - exerting up to 50 lbs. of force occasionally and/or up to 25 lbs. of force frequently.
• The employee is required to have close visual acuity including color, depth perception, and field of vision to perform an activity, such as assessing patients, preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• Frequent invasive and non-invasive patient contact.
• Exposure to patient body fluids as well as exposure to hazardous or poisonous materials.
• Ability to react quickly to emergency situations.