Why work for Nebraska Methodist Health System?
At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary:

Location: Westroads Office Park III
Address: 1120 N. 103rd Plz. - Omaha, NE
Work Schedule: Monday through Friday 8am - 4:30pm

A registered nurse who is part of the primary and specialty care practice team and is responsible for providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor outcomes.

The highest risk patients are identified via multiple sources to include:
• Patients identified by other health coaches, case managers and health care providers
• Patients with high risk scores identified by IT via HealtheIntent
• Those identified via IT algorithm as a rising risk patient
• Patients identified by insurance carrier as high risk

These patients will include:
• Uncontrolled or poorly compliant patients with COPD or heart failure
• Patients with frequent ER utilization
• Non-cancer patients admitted to inpatient services greater than two times in past year

The Care Navigator is an integral part of the primary/specialty care team is responsible for ensuring that the primary care physician (PCP)/specialist and practice team maintains a central role in coordinating and managing the care of these vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.

Responsibilities:

Essential Job Functions

1. Management of patients identified by the PCP/Specialist team as highest risk.

• Maintenance of a care management registry for documentation of highest risk patients, care management interventions, and care plans.
• Triaging high risk patients to identify the highest risk patients based on severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly-pharmacy, and health care utilization trends.
• Evaluation of and appropriate follow-up care for patients with frequent visits to the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
• Timely and ongoing communication with the PCP/Specialist and practice team to identify highest risk patients and to maximize the management of patient needs and related risk reduction.

2. Care management of highest risk patients to reduce risk, decrease hospital and ER utilization, and improve outcomes.

• Performs a comprehensive initial and ongoing assessment of patient’s physical, mental and psychosocial needs.
• Prioritizes data collection according to patient's immediate needs.
• Assuring that care is patient-centered and that the patient/family are informed about the plan of care, integrated in to the care coordination, planning and supported in decision-making.
• Coordinating care with other health coaches and care managers across the continuum of care and payers to maximize care and promote patient safety.
• Communicating/affirming patient needs, plan of care, and changes in status with the PCP, team and the patient/family.
• Oversight of the care coordination system for rising risk and high risk patients that is managed by the practice team.

3. Development of a tracking system for patient care coordination and care management across the continuum, including care transitions, referrals, report management, and two-way communication between the PCP, specialists, and/or other providers.

• Assure database is kept up to date.
• Identify patients overdue for visits, labs, referrals and arranging for follow-up services as appropriate and prescription refills.
• Identify patients who are not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
• Create patient, physician, and clinic level quality performance reports