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Ability to work as oversight for License Practical Nurse (LPN) for initial assessments, plan of care and supervisory visits including proper discharge of a patient from case management. Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
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Knowledge of nursing and case management theory and practice. Conducts/coordinates initial case management assessment of patients to determine outpatient needs. A minimum of 1 year of case management experience in community case management experience highly desired.
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Provides telephonic or outpatient visits to patients at high-risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, to disease management patients per the Disease Management Plan and to others as referred via transitional care team, acute case managers and Transitional Care team.
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For patients that are unable to come to the office—in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care physicians, and other resources that may be available depending on the market.
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The PCP is responsible for assessment, diagnosis, treatment, management, education, health promotion and care coordination and documentation for patients with acute and complex chronic health needs.
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PCP will have an active role in the management of their center and will help cover for other providers who may be out for various reasons. The PCP will work closely with the applicable managers and medical directors to ensure compliance with guidelines along with participating in risk and quality management programs, clinical meetings and other meetings as required that promote patient health and company goals.
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ChenMed, a physician-led and mission-driven, primary care organization, is currently one of the most successful full-risk Medicare Advantage providers in the nation and has a vision to be America’s leading primary care provider, transforming care of the neediest population.
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It is expected that the PCP will engage with the hospitalist whenever one of their patients is in the hospital (regardless of whether the hospitalist works for ChenMed or not). Were ChenMed and were transforming healthcare for seniors and changing Americas healthcare for the better.
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In order to achieve our vision and deliver our mission, we need the best primary care providers that are seeking to fulfill purpose and personal opportunity and join the ChenMed family. ChenMed is changing lives for the people we serve and the people we hire.
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The PCP leads their care team consisting of care promoter (medical assistant), care facilitator, and care coordinator for patients able to come to the office. Coaching for health: The PCP acts as a health coach, rather than just a consultant for sickness, by helping patients set short and long-term health goals, partners with the patient to work toward the goals, and frequently follows up on those goals on the path to improved health for their patients.
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We are an outcomes-focused, value-based organization and for their panel of patients, the following metrics are regularly measured to help PCP’s become successful and reach partnership status: patient admissions/thousand, using between 18-21 appointment slots per day (each new patient count for 2 slots, follow-up patients 1 slot), CGCAHPS (patient experience), clinical gaps closures, and medical cost measures.
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Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment. Our mission is to honor seniors with affordable VIP care that delivers better health.
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Self-Care — A PCP can take the best care for their patients when they are adequately caring for themselves. Once Board certified, PCP will maintain board certification in their specialty by doing necessary MOC, CME and/or retaking board exams as required.
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The PCP stays up to date on clinical, nutritional, and lifestyle-based interventions to improve outcomes. Evidence Based Medicine The PCP remains updated on evidence-based medicine, but also recognizes that factors outside of traditional medicine, like lifestyle and nutrition, have a large impact on patient health outcomes.
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Accountability for outcomes: The PCP demonstrates accountability for outcomes, strong clinical care, and cost-effectiveness for each patient in their panel of up to 450 patients. The PCP will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.
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case management jobs Company: Chenmed
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