Who are we?As an innovative primary care provider, Avance Care is in the business of improving the standard of healthcare. By offering convenient, accessible, cost-effective healthcare services, we keep our patients at the center!Role DescriptionTo establish, implement, monitor, and evaluate high quality, cost-effective care plans as patients move across the care continuum for a designed population.Core ResponsibilitiesReview of the patient's health status, medical and social, utilizing data from the electronic medical record claims, and additional resources shared with community providersOutreach to patients to confirm diagnosis, contributing factors, anticipated treatment plan, current and projected functional ability, and barriers to careAct as an extension of the primary care practice by partnering and collaborating with interdisciplinary team members across the continuum of careFacilitate access to necessary care by navigating barriers and advocating for the patient; educate patients and families/caregivers on the plan of care, the barriers to that care, and set expectations while setting achievable, safe goalsReview patients enrolled in care management each month to ensure treatment goals are met and the care plan is shared across the care teams, utilizing care coordinators as necessaryIntegrates the primary care team and Specialty Services (i.e. nutrition, behavioral health, medication therapy management), as applicable to support the achievement of health outcome goals with continuity of careEvaluate, coordinate, manage, and document all activities related to care management and ensure tracking of resource utilization and time is accurateComplete all required documentation in the electronic medical record; making team members aware/collaborating throughout the continuum of careCommunicate regularly with integrated team membersTrack patients who have had a recent ER visit, hospital admission, or inpatient procedure and reach out to provide support, maintain continuity of care between hospital and PCP, and reduce risk for readmissionAssist with primary care provider triage assessment and direct patient to appropriate servicesTrack patients throughout their care plan and perform a warm handoff to the appropriate next provider to care in the interval between primary care visits and care plan updatesDemonstrate initiative and creativity by identifying modifications in processes and workflows that will improve our ability to deliver cost effective, high quality careAssume accountability for professional growth and development, including a working knowledge of regulations/initiatives, trends in ambulatory and cross continuum care management, and accountable care organizationsUtilize information technology systems to identify high risk patients, contributing factors of risk and gaps in preventative and chronic care managementDevelop and maintain a sound working relationship with internal and external stakeholdersCollect data as needed within initiatives for ongoing analysisProvide clinical supervision for LPN, MA, CNA level staff for case conferencingApprove all final Care Plans for assigned paraprofessional staff.Coordinate patient case assignment for paraprofessional staff, based on clinical abilitiesAccomplishes all tasks as assigned or become necessaryQualificationsRegistered Nurse (RN) with current licensure in the state of North Carolina, requiredCase management experience, preferredBachelor's degree in healthcare of life-science related field, preferredMinimum of 1-3 years of healthcare experience with direct patient care, requiredExperience with home health nursing, health coaching/education, medication administration, and/or care for geriatric populations, preferredWhat are we looking for?Medical, administrative, and/or Customer Service experienceStrong written and verbal communicationKnowledge of common medical terminologyPatient confidentiality, HIPAATeam playerStrong computer skillsDetail-orientedStrong time management and workload prioritizationExtensive pharmacological knowledgeScheduleMonday - Friday 8:30am - 5:00pmTuesday's are in-person
