About this role
Essential Job Duties:
• Responsible for managing a group of patients throughout a ninety-day episode of care, as part of the Bundled Payment for Care Improvement (BPCI) Advanced program, Blue Cross Blue Shield Bundled patient and any other bundled programs.
• Completion of preoperative risk assessment and post op clinical care assessments.
• Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the continuum of care, including pre-operative, acute stay, Inpatient Rehab (if applicable), Skilled Nursing (if applicable), Long Term Acute Care (if applicable), Home Care (if applicable) and access to community resources (if necessary).
• Development and implementation of collaborative care plans throughout the continuum of care, specific to patient individual needs.
• Collaborate with physician and monitor all providers in the pre-operative, acute, post-acute and outpatient settings, to identify patient needs such as: home health care, DME, physical therapy and community services.
• Provide telephonic and/or onsite follow up with patients at planned intervals and as needed based on patient status.
• Complete and submit all required documentation within established guidelines.
• Input & maintain all files & documentation within care management system & practice medical record as appropriate.
• Ongoing evaluation and revision of plan of care as determined by patient's health status. Communicate changes to all providers and multi-disciplinary care team members involved in the patient's care.
• Identify gaps or barriers in the treatment plan and provide appropriate resources and services. Update care plan as needed throughout the continuum of care.
• Understand the BPCI and other Bundle programs design, implementation, management, monitoring and reporting requirements.
• Remain flexible and responsive when changes occur in patient activity and workload.
• Maintain patient confidentiality and HIPAA compliance.
• Perform other duties as assigned.
Education:
• RN Preferred
• LPN with 10 years of experience
• Education and experience considered for negotiation
• Licensed to practice Nursing in Mississippi
• 2-3 years' of Nursing experience required; orthopedic experience is highly preferred; experience in discharge planning and outpatient care coordination preferred
Other Requirements:
• Exceptional customer service, interpersonal skills, and communication skills;
• Proficiency of electronic records systems preferred. Must have strong data entry skills;
• Must be able to complete tasks with a high-degree of efficiency and accuracy while working in a fast-paced environment with frequent disruptions;
• Must demonstrate ability to analyze data and resolve complex problems;
• Must have the ability to work independently while managing time and workload appropriately;
• Must be able to travel to various locations and work overtime hours as needed.
Job Type: Full Time- On Site