Summary:

Provides and supervises care under the direct guidance of the Population Health Manager and Director of Care Management utilizing physician approved patient protocols according to established standards and best practice guidelines. Supervises the facilitation of the communication between patient/caregiver, physician and the outpatient care team to optimize health and wellness, reduce inpatient admission, reduce re-admissions and improve medical stability in the patient population served. Works collaboratively with Nurse Navigators and department leadership to manage medical stability in patients with high risk disease management with complex comorbid conditions.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Manages a small case load with identified gaps in care in collaboration with the Health Care Team.
• Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable.
• Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers.
• Reviews patient medical record to identify care gaps.
• Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter.
• Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services.
• Assists Nurse Navigators? in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines.
• Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing.
• Serves as a facilitator of a collaborative approach with care team for identification of and closure of care gaps.
• Designes and utilizes educational and behavioral change strategies to promote patient collaboration with the care team.
• Incorporates excellent written, verbal and listening communication skills, positive relationship building skills and problem solving into patient care coordination practice.
• Performs all necessary administrative taks for direct reports.
• Performs duties as required or assigned for specific operational purposes for which they are qualified to perform.
• Maintains all professional CEU?s in compliance with State and Regulatory requirements.
• Supports leadership with the selection, training, development, appraisal, work assignments, performance management, staffing and productivity of Associates within Population Health Care Management.

• Ensures and/or provides formal, structured orientation/training process for new Associates with regular opportunity for feedback and assessment of competency upon completion.
• At direction from the manager, supervises daily LVN CC activities of Population Health Care Management clinical staff, individually and as a team to ensure the following objectives are met:
       
• Maintains appropriate staffing ratios and team assignments based on volumes.
       
• Responsible for development and maintenance of policies and procedures for department.
       
• Responsible for HIPAA and Integrity compliance within department.
       
• Works closely with department Manager and Director to identify and plan for opportunities for improvement within areas of responsibility.
• Must be knowledge of lab procedures and diagnostic testing.
• Must have the ability to write clear documentation and ability to write detailed specifications.
• Must have solid organizational skills including attention to detail and multi-tasking skills.
• Must have basic computer skills.

Job Requirements:

Education/Skills

• Vocational/technical school graduate required.
• Must have basic LVN Nursing skills.

Experience

• 5 years clinical experience with at least 3 years in a primary care clinic preferred.
• EMR experience required.

Licenses, Registrations, or Certifications

• LVN/LPN License in the state of TX or where position is located within the enterprise required.
• BLS preferred.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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