SUMMARY OF RESPONSIBILITY:
The Care Continuum Specialist (CCS) is an LPN responsible for ensuring the continuity of patient care, as they transition out of the acute care setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. The CCS facilitates the continuum of patients’ care utilizing nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Coordinates and manages care to meet multiple clinical and resource needs of members, ensures continuity of services and overcomes fragmentation of care and services. Model and facilitate new behaviors, skill transfer, and communication strategies for patients and families to build confidence that they can successfully respond to common problems that arise during care transitions. The patient's goal drives the agenda.
ESSENTIAL FUNCTIONS:
Embraces the population health philosophy of "home first" providing support and resources for patients transitioning to home.
Builds relationships with partnering hospitals as well as post-acute care facilities/agencies to promote utilization of evidence-based best practices and efficient methodologies to provide safe, quality care across the health care continuum for the patient.
Identifies and refers appropriate members for transitional care management and complex care management
Utilizing industry standards provides transitions management through medication reconciliation and review, red flags/ signs and symptoms management, patient/caregiver education, Provider follow-up appointment, identification of SDOH barriers and condition education.
Develops and maintains documentation of individual plan of care based on patient’s health assessment.
Acts as a liaison between the patient, the PCP, interdisciplinary care team and hospital staff. Maintains regular contact with the patient’s PCP. Advocates on the behalf of the patient to identify the most appropriate institutional or community resources and assists in closing the gaps.
Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Provides appropriate education for the member and their support system on management of their disease.
Identifies resources in the Trinity Health services continuum.
Other duties as assigned
THE DUTIES LISTED ABOVE ARE INTENDED ONLY AS ILLUSTRATIVE OF THE VARIOUS TYPES OF WORK THAT MAY BE PERFORMED. THE OMISSION OF SPECIFIC STATEMENTS OF DUTIES DOES NOT EXCLUDE THEM FROM THE POSITION IF THE WORK IS SIMILAR OR A LOGICAL ASSIGNMENT TO THE POSITION.
QUALIFICATIONS AND COMPETENCIES:
Valid, unrestricted license in the state of practice, as a licensed practical nurse, graduate from an accredited program in professional nursing. May be required to obtain additional licensure in secondary state.
Five years’ clinical experience and three years managed care experience.
Valid Driver's license
Experience in Care Coordination or Transitions of Care is required.
Experience with geriatric population preferred
Demonstrates effective team behavior, supporting other team members and working to support achievement of team objectives.
Understands relevant accreditation and licensing requirements in assignments.
Ability to be non-judgmental regarding living and health-related decisions.
Ability to work with members and families with diverse opinions and diverse religious and cultural ideas and values. Ability to work autonomously with little direction and be directly accountable.
Possesses a working knowledge of available community resources or willingness to learn.
Possesses a working knowledge of basic computer software
PHYSICAL AND MENTAL REQUIREMENTS:
The Physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to work long hours – over eight in a work day, and over 40 in a work week as necessary;
Regularly required to use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms; and talk or hear.
Frequently is required to walk and sit.
Occasionally required to stand; climb or balance; and stoop, kneel, crouch or crawl.
Ability to lift and/or move up to 20 pounds.
Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The dexterity necessary to utilize a computer keyboard on a regular basis is essential.
Some travel may be required