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PriMED Physicians is one of Dayton's largest and fastest growing independent medical groups. PriMED has medical offices located throughout the Dayton area. Each office is staffed with a team of compassionate professionals that focuses on our mission to provide exceptional comprehensive health care to our patients. Complex Care Managers target high risk patient populations to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Coordinates with the Primary Care Physician (PCP) and functions as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care settings. Ensures continuity of care through defined, evidence -based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care giver, health education and referrals. Collaborate with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources. Full Time Day Shift Mostly remote, must attend meetings onsite Must reside near Dayton, OH Essential Duties and Tasks Engage in weekly care conference between the care management team which includes the LPN PCC, the Complex Care Manager and the PCP. Use of the Care Conference Tool in Tableau to capture patients for enrollment to care management and to add for discussion during Care Conference Facilitation of Patient Centered Care Identifies, evaluates, engages and enrolls high risk members of specified populations Performs complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources Based on assessment and in conjunction with patient/family/caregiver, provider and other healthcare team members, participates in the development of an initial Plan of Care and Self-Management Plan that highlights actual and potential opportunities for improving clinical outcomes and/or utilization patterns and decreasing gaps in care Facilitates and monitors implementation of Plan of Care Coordinates patient/family/caregiver participation in Plan of Care and self-management Uses knowledge of community resources to facilitate achievement of goals Coordinates patient education to achieve Plan of Care using evidence-based methods such as teaching back. Other duties as assigned Interdisciplinary Practice Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post-acute and home settings Demonstrates expertise in case management and serves as a resource to the interdisciplinary health care team Integrates knowledge of external and internal regulatory requirements into the review and management of cases Works in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care Serves as bridge across the clinical setting and functions as patient's consistent point of contact Facilitates referrals to other disciplines and internal health and community-based programs as appropriate to improve patient outcomes Evidence-Based Care Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-Process Metrics, NCQA, URAC and HEDIS) when coordinating and facilitating Plan of Care Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice Measurement and Reporting Documents in the medical record as indicated and designated care management enrollment accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals Qualifications, Education and Experience Registered Nurse (RN) with Active State License - BSN preferred 3 years minimum in nursing with 2-year care management preferred Be able to work flexible hours as needed Must demonstrate strong verbal and written communication skills Must demonstrate ability to work as part of the team Must be able to organize, prioritize and maintain a flexible attitude Physical Demands 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. This role routinely uses standard clinical and office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Employee is regularly required to stand; walk; use hands/fingers to type, hold, handle, or feel; and reach with hands and arms. The employee is regularly required to talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Other Duties Always take ownership and be accountable for your actions. This job description is a tool for you to follow while at PriMED Physicians. Other job duties may be assigned to you, this outline is not to be considered a detailed description and you may have other duties/projects assigned to meet business needs. Good and reliable attendance, positive attitude and at or above job specific goals will reflect on your annual review. Always take ownership of your job and team. EEO Statement PriMED Physicians provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other classification protected by the state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.