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Job description
If you are a current Duly/SBC/QMG employee, please apply through the Internal Career Site.
Department : VBC Operations
Location : Eddy Street Campus – 211 N. Eddy Street, South Bend, IN 46617
Hours : 40 Hours Weekly | Monday-Friday
At The South Bend Clinic , you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do.
With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.
Benefits
Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
Access to a mental health benefit at no cost.
Employer provided life and disability insurance.
$5,250 Tuition Reimbursement per year.
Immediate 401(k) match.
40 hours paid volunteer time off.
A culture committed to community engagement and social impact.
Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.
Responsibilities
Patient Care / Patient Education
Assumes an active role in the planning and implementing educational needs of assigned patients, with direct care team and need consultants: Diabetic Educator, pharmacy, dietary, wound care, etc.
Coordinates assigned patients' clinical care plan in conjunction with the Primary Care Provider and with appropriate team members and communicates the plan to patient/family in a timely manner.
Review services with interested patients and assist in enrolling them in the CCM program
Provide all services necessary in order to execute an electronic care plan
Determine an individual’s health and educational needs as a result of inbound and outbound phone calls, and review of medical records with patients
Maintain communication with patients to measure no less than 20 minutes per month
Collaborate with the patient's provider to facilitate appropriate physical, behavioral and social services
Review care plans and make changes as necessary
Provide patients with information regarding medical questions/concerns
Examples of CM activities may include educating newly diagnosed patients about the disease and treatments; managing therapies; and drug administration and side effects
Care Facilitation
Develops, manages, and drives clinical plan of care with physician and multi-disciplinary care team.
Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure timely patient management and facilitation of services.
Coordinates patient care across the care continuum to reduce fragmentation of care and addresses/ resolve system issues that may be impeding progress and quality of care for patients.
Focuses on management of the complex patient with the goal of patient self-management, quality outcomes, and resource utilization goals.
Identifies and refers patients for social worker intervention, as well as transitions of care follow up at home.
Addresses complex clinical situations efficiently, to avoid unnecessary delays in care.
Obtains the support of the social worker for complex social issues, behavioral problems, home and family issues, placements, guardianship, hospice, palliative care referrals, drug and alcohol abuse, and violence.
Utilization Management
Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post-acute care needs daily.
Coordinates with post-acute partners and facilities to ensure efficient care and patient-centered transitions.
General Responsibilities
Exhibits computer systems knowledge and proficiency as necessary to perform job functions.
Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards.
Performs other duties as assigned when appropriate.
Adheres to HIPAA guidelines set forth in Clinic policies and procedures.
Education/Certification/License
POSITION REQUIREMENTS
Minimum of an unencumbered license as a Registered Nurse in the state of Indiana.
Knowledge, Skills, And Abilities
Must have experience in case management or care management (Certified Case Manager preferred)
Must have experience with Medicare/Medicaid
Experience with multiple EHR/EMR systems
Ability to work collegially with staff members from multiple offices
Ability to manage multiple patients simultaneously
Ability to build and maintain relationships with patients, families and client providers
A background in geriatric care, family medicine and/or long-term care (skilled nursing, home health, hospice, public health, assisted living) highly preferred.
A background and ability to work with populations with special needs
Competence and experience with electronic charting
Ability to multitask
Excellent written and verbal communication skills.
Self-directed with the ability to work independently and in groups
Exceptional time management skills, with a high level of individual initiative
Detail oriented with strong organizational, planning, and problem solving skills
Can be depended upon to effectively plan and organize multiple assignments to ensure workload’s completion, yet flexible enough to handle changing schedules
Special Demands/Requirements
Occasional, local travel may be required for off-site meetings.
INDHP
Artificial Intelligence Disclosure
Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.