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Under administrative direction, coordinates and integrates a continuous and comprehensive interdisciplinary plan of care for patients utilizing a holistic and patient-centered medical home approach; assesses, plans, implements, monitors, documents, and evaluates the continuum of care in collaboration with primary care providers and the health care team; facilitates options and services to meet the patient’s health care needs including access to care, engagement, and education in self-care, and care coordination with community services and family members; develops and implements patient centered strategies to improve management of chronic conditions, improve clinical outcomes, and enhance patient satisfaction.
Knowledge of the concepts and principles of managed care
Interpersonal/human relations skills with ability to relate to diverse groups
Demonstrated leadership qualities including time management skills
Verbal and written communication skills
Problem solving and decision-making skills
Critical thinking skills and ability to analyze complex data sets
Strong proficiency in use of personal computer software and databases, including the use of electronic health records and manipulation of statistical data
Demonstrated ability to work autonomously and be directly accountable
Demonstrated ability to influence and negotiate individual and group decision making
Demonstrated ability to function effectively in a fluid, dynamic, and rapidly changing environment
Ability to prioritize, delegate, and organization work
Ability to maintain a high level of confidentiality
Bachelor’s degree, with a masters degree in nursing or public health preferred; supplemented with three (3) years experience in clinical nursing. Missouri RN licensure required. Certification as a case manager and experience in case management strongly desired.
Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency, and the delivery of healthcare for medical home patients.
Assesses plans, implements, coordinates, monitors, documents, and evaluates options, and services to optimize the member’s health status.
Develops systems of care that monitor member’s progress and promote early intervention in acute care situations.
Supervises staff; establishes and promotes a collaborative relationship with health care providers, payers, and other members of the health care team to optimize interventions.
Manages utilization and practice metrics to refine the delivery of care model to maximize clinical, quality, and fiscal outcomes.
Performs special projects and other duties as assigned.
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