Job Opportunity
Job ID:46960 Positions Location: Lansing, MI Job Description General Purpose of Job: As part of a larger
Description:
Positions Location: Lansing, MI Job Description
General Purpose of Job:
As part of a larger population health strategy, this position will work in collaboration with the primary care providers and members of the PHSO team to identify eligible patients for appropriate annual outreach and provide a nurse-led Medicare Annual Wellness Visit (AWV). Work will include reviewing registries, assisting with scheduling, completing standardized visits via telehealth technology or in-person visits, supporting referral coordination, and acting as a community resource for Medicare beneficiaries. This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care, and the ability to proactively recognize risk factors within complex patient populations. Common Duties and Responsibilities:
The nurse-led Medicare AWV work within the PHSO will be new for the larger health system. The nurse will contact patients to schedule and complete the required components of the AWV according to the Centers for Medicare & Medicaid Services (CMS) guidelines; this will minimally include completion of a comprehensive assessment of the patient's health status, diagnosis reconciliation, completion of the Health Risk Assessment (HRA), screening for Social Determinants of Health (SDOH), medication reconciliation, Advanced Care Planning (ACP), and making recommendations per protocol for preventative/screening and chronic condition interventions according to standardized guidelines. Additionally, through comprehensive medical record review, the nurse will identify opportunities for accurate coding/documentation considerations and provide pre-visit planning documentation to assist the provider in recognition of conditions due for reassessment. Essential Duties: This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
- Reviews the clinic schedule/registries and identifies patients appropriate and due for an AWV.
- Works collaboratively with the clinical team to accomplish the visits in an efficient manner.
- Follow AWV protocols and standing orders including completion of preventive services that may result from a visit.
- Addresses open quality gaps with the patient and works collaboratively with the individual to close care gaps.
- Identifies risk capture opportunities and works collaboratively with providers to update problem lists and other risk identifiers.
- May assist with coordination of care needs identified in the AWV, such as patient messages, requesting refills, or other care needs that are discussed in the visit.
- Participates in regular team meetings/communication, huddles, staff meetings and quality improvement projects to improve patient care.
- Consults with the clinical/ancillary office staff to eliminate barriers to the efficient delivery of care.
- Assists the patients and/or families in recognizing and prioritizing the problems that need to be addressed.
- Problem solves with patients and their families to maximize their ability to follow preventive, remedial and/or rehabilitative recommendations.
- Educates and supports office staff in providing care coordination.
- Develops and maintains an effective professional working relationship with all patients, families, physicians /providers and health care team members.
- Develops and maintains an effective professional working relationship with specialists and facilities (including hospitals, home health care and other ancillary providers) with which Sparrow Medical Group (SMG) physicians have ongoing relationships.
- Develops, recommends, and implements a plan, in conjunction with the patient, family and health care team, which addresses the problems and needs identified in the assessment.
- Provides or arranges chronic disease education (as appropriate) for patients and families as needed.
- Provides consultation services for other department staff.
- Assists in developing a process to track care coordination activities.
- Assists in developing written procedures and/or guidelines on care coordination processes and trains appropriate care team members on the processes.
- Educates and supports office staff in performing a comprehensive assessment.
- Screens selected cases to identify needed services and interventions to deliver quality comprehensive care that addresses the patient's full range of health care needs.
- Identifies issues, which may impact medical outcomes based on a comprehensive assessment that may include the patient's medical condition, support systems, finances, living situation, housing, behavior, cognition, function and abilities, and the patient's choices and preferences.
- Refers patients/family to other support resources to achieve health outcomes (i.e. Chronic Care Management, Navigation Hub, Behaviorial Health Support, etc.)
- Works with office staff as part of an Interdisciplinary Team, develops and implements a plan which addresses problems and needs identified in the assessment and ensures continuity of care by:
- Assisting patients and family with access to appropriate resources and services based on a thorough knowledge of community resources and eligibility requirements.
- Advocating on behalf of patients and their families with internal/external resources and payers for needed services, including negotiating with insurance companies for non-covered benefits.
- Communicates with patients, families, members of the health care team and others in a professional, diplomatic, and empathetic manner.
- Provides clear, concise, timely written documentation on the patient's medical record and on departmental records.
- Collaborates with other members of the Sparrow Health System (SHS) departments to collect, analyze, and utilize data for quality / process improvement.
- Participates in activities which support and advance the department and SHS's mission, vision, and goals to improve outcomes and operations.
- Attends mandatory department and SHS meetings and training sessions.
- Provides or arranges education for patients, families, physicians, and other members of the health care team, to enhance patient care or improve department outcomes and operations.
- Supports the development of new policies/procedures to ensure documentation is in place for the remote work.
- Reviews payer requirements and acts as the Subject Matter Expert (SME), as the PHSO reviews opportunities to expand the support staff.
- Works closely with the Business Intelligence/Information Technology (BI/IT) team to create new dashboards and track internal productivity.
* Job Requirements
| General Requirements |
* Registered Nurse with a current Michigan license |
| Work Experience |
* Minimum of two years of nursing/care management experience in primary care, community care or home health. |
| Education |
* Bachelor's degree in nursing or health care related field OR must complete within 2 years of hire |
| Specialized Knowledge and Skills |
* Demonstrates excellent clinical knowledge, skills, and judgment. * Demonstrates excellent communication skills that include emotional intelligence, relationship building, negotiation, conflict resolution, persuasion, marketing, and patient advocacy. * Demonstrates comprehensive case management assessment skills, with the ability to proactively and creatively problem solve. * Demonstrates the ability to prioritize, organize, handle many tasks simultaneously, work autonomously, and manage time well. * Demonstrates the ability to work in stressful situations, manage conflict, and assume a leadership role. * Knowledge of case management that includes but is not limited to health care finance, hospital and community resources, discharge planning, utilization review, utilization management, ethical case management principles and evidence-based practice concepts. * Experience with an EMR. Preferred: * Knowledge and demonstrated ability to collect, analyze and utilize data for process improvement. * Previous experience with Annual Wellness visits * Previous experience with / knowledge of CMS risk adjustment coding and documentation |
University of Michigan Health-Sparrow is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status. #LI-MR1
Job Family
Registered Nurses/Nursing Leadership
Requirements:
| Shift |
Days |
| Degree Type / Education Level |
Bachelor's |
| Status |
Full-time |
| Facility |
Sparrow Hospital |
| Experience Level |
Under 4 Years |
|
Sparrow Health System
remote work
Dec 13, 2024