R210402 Department: 39733 Enterprise Corporate - Care Transitions      Status: Full time    Benefits Eligible: Yes    Hours Per Week: 40    Schedule Details/Additional Information: Remote, work from home position. Requires high-speed internet. Potential to include weekend and holidays. Exempt position, Monday-Friday, 1200-2030.         Pay Range $37.50 - $56.25    Major Responsibilities:

• Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.
• Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team.
• Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.
• Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements.
• Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.
• Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care.
• Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.  Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.  Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.

Education Required:

• Bachelor's Degree in Nursing or related field.

Experience Required:

• Typically requires 5 years of experience in clinical nursing or 1-2 years of care management experience.

Knowledge, Skills & Abilities Required:

• Applicable certification is encouraged.
• Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
• Ability to demonstrate excellent oral, written and interpersonal skills.
• Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
• Ability to work productively and effectively in a complex environment that includes multiple changing priorities.
• Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.
• Proficient computer/Microsoft-suite skills and previous Epic EMR experience.
• Ability to handle multiple responsibilities.

Physical Requirements and Working Conditions:

• Position may require travel between clinic sites so there may be exposure to road and weather conditions.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment; including usual hazards related to operating electrical equipment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.     Our Commitment to You:   Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:   Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

  Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

        About Advocate Health    Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.