Primary responsibility is to provide care coordination for the high risk population of the practice. This will include developing and managing processes that directly improve care management and care coordination for the primary care practice population. Functions as the care team coordinator and communicates with all members of the team to ensure patients progress toward individual health care goals. Assists the patient care team in providing the highest quality of care to the primary care practice population in a cost effective manner. Collaborates with the patient care team to move populations through the continuum of care and develops structured care methodologies. Evaluates complex patient progress, intervening and facilitating as necessary to ensure optimal patient outcomes. Must demonstrate clinical expertise and must role model the application of clinical practice standards in assigned patient populations including but not limited to: Reduce avoidable admissions and 30 day readmissions for the practice population.

Transition of care management:

coordinates care for all patients discharged from post-acute settings such as skilled nursing facilities, swingbed, rehabilitation services, hospitals, and long term care facilities. Facilitates access to care for the practice population. Ensures processes are in place for the practice to increase same day access and reduce no show rates with high risk vulnerable population. Reduce avoidable ED use. Identify trends in ER use by practice population and collaborate with practices to engage members to use primary care provider for primary care.

Chronic Disease management:

Use risk stratification tools and predictive modeling to identify high risk patients for case management and focused improvement initiatives. Create individual plan of care for high risk population.

Patient Engagement:

Develop relationships with high risk population by gaining trust, building on patient's current knowledge of disease processes, development of self-management action plans, setting goals with high risk population, and partnering with patients to maintain new behaviors.

Disease Prevention:

Monitors individual cases and intervenes as indicated to ensure timely utilization of resources,

Pre-Visit Planning:

Identify and contact high risk patients with care gaps prior to their scheduled appointment. Coordinate care and ensure results are available prior to appointment with physician.

Post-Visit Planning:

Follow up with high risk population to ensure individual plan of care is being followed. Assess patients progress toward individual goals and notify physician when issues arise that prevent patients progress toward individual health care goals.

Medication Compliance:

Assess patient's adherence to medication plan, including identification of barriers. Identify and utilize resources to best meet the patient/family needs including community resources and financial resources to improve compliance.

Wellness:

Assess payor benefits of high risk population and coordinate care including follow up of recommended screening services based on age, gender, and conditions. Develops systems for information collection and data mining. Actively works with Information Systems staff to integrate information technologies into daily practice operations. Acts as a disease registry expert, anticipates patient needs, assists in identifying at risk/high risk populations through evidence based care. Interprets data on a routine basis and communicates with the care team and patients to improve patient outcomes. Proactively plans care to ensure tests and services are completed or requested prior to the office visit and assists in setting the patient agenda prior to the scheduled office visit. Collaborates with physicians, administration and all office personnel to develop and implement strategies to improve clinical outcomes. In collaboration with the primary care provider, coordinates post visit follow up to ensure compliance with individualized care plans. Actively engages patient in self-management and education. Develops relationships with patients and promotes confidence and motivation in self-care to promote wellness and optimal health. Leads organizational strategies to promote patient-centered care and improve the patient experience. Oversees performance improvement initiatives, including development of detailed strategic plans to improve the health of the practice population. An expert with Performance Improvement Methodology. _We believe a career is more than just a career - it's a calling. Our teammates' \"True North\" is what calls them to health care; it's their passion. At North Mississippi Health Services, we believe in helping you leverage and connect that passion with a much greater purpose that impacts people you know and love._ #NMHSConnections