Personal Health Senior Nurse - Remote

JOB SUMMARY

Conifer uses a holistic approach to medical management.  The Sr. Personal Health Nurse (PHN) works within a team to move the participant through the continuum of medical management with the goals of facilitating quality health care through the most cost-effective means.    The Sr. PHN performs the Personal Health Management process: assess the participant; work with the participant, family, and physician to identify problems; establish goals and develop plans of care; coordinate services; educate participants; and empower participants to independently self-manage and to make knowledgeable health care decisions. The Sr. PHN works closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s) by performing functions of Personal Health Management as well as some functions of Utilization Management. Additionally, the Sr. PHN interfaces with clients and with Conifer account managers and are responsible for the medical management of designated account(s).  All Medical Management Nurses practice within the scope of their licensures.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Manages accounts using the 4-Pronged approach, meeting expected number of billable hours and using Conifer Value Based Care tools (CCOO) according to standard protocol. Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity
• Reviews daily calendar for new episodes and tasks due, prioritizes tasks on calendar
• Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the participant and the physician’s assessment and treatment plan
• Determines and documents participant’s goals, engages the participant in the personal health management process.  Develops an ongoing individualized plan of care with timeframes reasonable and appropriate expected outcomes, specific planned interventions and participant’s goals. Follows through with interventions and documents outcomes in Current Clinical Status section of care plan. Documents each component thoroughly: treatment plan, diagnoses, cost savings
• Engages the PCP and treating physicians in the personal health management process, Collaborates with the participant and PCP in development of an individualized plan of care
• Closes episodes as indicated, i.e. evaluates “Impactability” among other indications for closure.
• Assesses and documents clinical and behavioral outcomes, Consults with IMMS Medical Director on issues of concern about participant treatment plans, Refers all participants who have a patient severity of “high” to case management, Triggers and reviews participants,
• Identifies liability issues associated with the performance of medical management, Identifies and documents financial outcomes according to Conifer’s ’s standards
• Participates in account meetings, Reports any account issues or questions to the TL on the account
• In collaboration with the TL, identifies and brainstorms areas that may be improved, Acts as a resource to nurses on the team

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Functions independently
• Understanding of Conifer’s holistic approach to medical management
• Understanding of the client’s (customer’s) perspective and needs
• Understanding of legislative acts, such as the ADA
• Adheres to of the CMSA Standards of Practice, Adheres to CMSA Standards of Practice and Professional Code of Ethics
• Advocates for participant to obtain quality health care
• Understands purpose of URAC  knows how to access the standards
• Uses Milliman Care Guidelines
• Competency with Conifers Web-based products as they relate to case management, including referrals, Clinical Claims Chart, EBM, Risk Stratification, etc.
• Knows how to access and uses the Summary Plan Descriptions (SPD)
• Competency in Word
• Competency using email, attachments
• Excellent verbal communication skills with the ability to communicate with participants and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, account managers, brokers, customer service staff, Conifer executive management, other Conifer Medical Management nurses, hospital utilization review nurses, etc.
• Excellent written communication skills with the ability to write in a professional, business manner
• Ability to