Job Summary

This role supports care management activities and value-based care initiatives for ambulatory services, specifically within the medical group. Performs all duties as assigned.

Job Responsibilities

• Collaborate and participate in Baptist Medical Group’s care management and value-based care initiatives.
• Provide education to patients and caregivers regarding self-management of health care conditions that are appropriate based on language, cognitive abilities, literacy levels, patient preferences, and readiness for change.
• Facilitate the transition of patient care from inpatient settings such as hospitals, rehabilitation facilities, and skilled nursing facilities back to the patient’s home or community setting.
• Develop a comprehensive, collaborative care plan, based on the provider’s treatment plan.
• Assist patients with care coordination needs, including provider referrals, medication refills, appointments, and preventive screenings, as appropriate.
• Promote patient adherence to provider recommendations and treatment plan.
• Collaborate with providers to strengthen clinical documentation and support risk adjustment initiatives.

Experience:

Minimum Required

• 3 years of nursing experience on current unit or in specialty area.

Preferred/Desired

• Experience with care coordination, case management, or utilization review processes.

Education:

Minimum Required

• BSN or equivalent years of nursing experience

Special Skills:

Minimum Required

• Strong analytical and data management skills. Comfortable seeking direction and assistance from appropriate resources. Ability to communicate effectively verbally and in writing. Proficient ability to use a computer and electronic medical record. Comply with all.