PA
Primus Valor AGLeiter Immobilienvertrieb – m/w/d
Head of real estate sales leading sales strategies and team development for residential properties in Germany. Responsible for the strategic direction and performance of the sales department.
About the role
- Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
- Meet the patient where he/she is; observe the patient without intervention or judgment.
- Has knowledge of common chronic medical conditions presented in the population served and is able to: Educate the patient on their medication conditions and medications, and build their self-management skills.
- Use motivational interviewing to promote behavioral change.
- Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
- Conduct medication reconciliation in conjunction with the clinical pharmacist.
- Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs.
- Coach and guide member/representative to meet bio/psycho/social goals.
- Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
- Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
- Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
- Participate in local site operations, including team meetings.
- Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO.
- Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible.
- Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.
- Understand the relationship between work done in the ACO's system and the work done in EHR.
- Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
- Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
- Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
- Maintain HIPAA standards and confidentiality of protected health information.
- Adhere to departmental/organizational policies and procedures.
- Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
- Participate in the integrated care team meetings and rounds as required.
- Maintain accurate, timely documentation in electronic systems including health center EHRs.
- Provide coverage for team members who are out of office.
- Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM.
- Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.
- Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
- Ensure that all necessary accommodations are consistently made for members with disabilities.
- Promote a sense of teamwork through demonstration of self-direction and self-motivation.
- Solve problems independently or know when to seek consultation.
- When onsite, co-locate near the medical nursing and provider teams for teambuilding.
- Perform other duties as assigned by the Lead Chronic Care Nurse or designee.
Requirements
- Bachelor of Science degree in nursing required
- Must be licensed in Massachusetts as a Registered Nurse
- Experience in nursing with recent clinical experience in outpatient medical setting or other related outpatient practice preferred
- Must have demonstrated solid interpersonal, communication, and management skills
- Must be able to continually update clinical knowledge and skills through formal and informal education and review of current literature
- Must have knowledge of ambulatory and clinical practices, workflows, and operations
- Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions
- Must exercise a high degree of professional judgment within the scope of licensure
- Experience working with historically underserved populations preferred
- Bilingual (Spanish, Portuguese, or Haitian Creole) strongly preferred
- Experience with Patient Centered Medical Home model and concepts preferred
- Must have a willingness to work flexible hours to meet the organization's needs/demands
- Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed
- Must have excellent communication skills, particularly with people from diverse cultures whose primary language is not English, with the ability to understand the community, population, and patients we serve
- Must have experience working with diverse cultures
- Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.
Benefits
- Medical & Dental Insurance
- Short & Long-term Disability Insurance
- Generous Paid Time Off
- Flexible Spending Account
- Employee Assistance Program
- Tickets at Work
- Health Reimbursement Arrangement
- Travel Reimbursement
- Professional Development Opportunities
- Solid track record of developing and promoting employees internally
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