Clinical Case Manager, RN

Job Description Summary ‎ The ACO Clinical Manager is primarily responsible for the day to day operations of an integrated multi-disciplinary clinical and clinical support structure that will effectively monitor, support, and lead ACO clinical initiatives. This includes but is not limited to case management, discharge planning, care coordination and continuity, provider/staff education on ACO/MA Plan clinical programs, and helping to build and maintain a network of community support. This individual must exhibit strong leadership, management, and interpersonal skills, as well as the ability to utilize both internal and external resources to accomplish the goals and objectives of the organization. ‎ How will you make an impact & Requirements ‎ Hours Monday-Friday 8am-5pm-Full-Time This is a traveling role

• 3 days a week to offices in Melbourne/Vero Beach 2 days will be working from home (schedule can vary) Essential Duties and Responsibilities include the following.

Other duties may be assigned. Effectively manage day to day ACO/MA Plan Clinical Programs to enhance clinical efficiencies Identify opportunities for increased outpatient vs. inpatient utilization Utilizes data provided to help in managing population health needs and implements population programs for ACO/MA Plan beneficiaries Execute case management for patients identified at highest risk for adverse event or exacerbation having ability to impact, with goal of decreasing unnecessary emergency department visits/hospitalizations Oversee extended patient care team including but not limited to: Social Workers, Emergency Department Liaisons, Behavioral Health Liaisons, and Home Health Liaisons. Oversee smooth Transitional Care Management for all patients discharged from in patient facility (hospital, skilled nursing/rehab, behavioral health) ensuring: Primary Care Provider visit, DME and Home Health Services, Specialist appointments, and community resources/social services are provided as indicated. Ensure Quality Measures are reviewed and addressed when applicable/appropriate Implement and direct ACO/MA Plan Health Education Activities for beneficiaries, providers, and staff

Human Resources Job Description:

Community Outreach Liaison Rev. 8/15/17 Participate in Care Coordination and Quality Committees, Primary Care Provider POD Meetings, Hospitalist POD Meetings, Hospital Joint Operation Meetings, JOC Meetings, and other meetings as required Monitor corporate initiatives and strategies to achieve utilization of business and financial goals Manage the successful integration of ACO Programs into current operations to meet the goals of all stakeholders Maintain collaborative relationships with business partners both within the company and the community Manage and execute organizational opportunities and implement changes that are in alignment with corporate financial goals and strategic endeavors. Competencies To perform the job successfully, an individual should demonstrate the following competencies: Analysis/Problem Assessment

• Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships. Compassion
• The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality. Compliance
• Employee has satisfactory completed employers required compliance training. Employee is able to demonstrate an understanding of employers Code of Conduct. Communication
• Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills. Dependability
• Meets commitments, deliverables, deadlines, work independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, and meets attendance/punctuality requirements. Individual Leadership/ Influencing
• Using appropriate interpersonal styles and methods to inspire and guide individuals (fellow employees) toward goal achievement; modifying behavior to accommodate tasks, situations, and individuals involved. Innovation
• Generating creative solutions to work situations; trying different and novel ways to deal with organizational problems and opportunities. Integrity
• Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities. Judgment/ Problem Solving
• Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others. Maximizing Performance
• Establishing performance/development goals, coaching performance, providing training, and evaluating performance. Organizational Awareness
• Having and using knowledge of systems, situations, procedures, and culture inside the organization to identify potential organizational problems and opportunities; perceiving the impact and the implications of decisions on other components of the organization. Patient Service Orientation
• Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating

Human Resources Job Description:

Community Outreach Liaison Rev. 8/15/17 and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence. Planning and Organizing/ Work Management

• Establishing a course of action for self to accomplish a specific goal; planning proper assignments of personnel and appropriate allocation of resources. Results Driven & Execution
• Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative. Teamwork/ Collaboration
• Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions. Work Standards
• Setting high goals or standards of performance for self, direct reports, others, and the organization; being dissatisfied with average performance; self-imposing standards of excellence rather than having standards imposed by others.

Qualifications 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. Education and/or Experience

• Bachelor's degree from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience. Language Skills
• Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Mathematical Skills
• Ability to apply basic mathematical concepts. Reasoning Ability
• Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. Computer Skills
• To perform this job successfully, an individual should have knowledge of Electronic Medical Records (Athena Database software); Microsoft Spreadsheet software and Microsoft Word Processing software; including Excel.

Certificates, Licenses, Registrations Registered Nurse Preferred Physical Demands Human Resources Job Description:

Community Outreach Liaison Rev. 8/15/17 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to sit. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is occasionally exposed to outside weather conditions. The noise level in the work environment is usually moderate depending on the business activity of the office.