Major Responsibilities:

• Facilitates communications among the employee/family, employer clinic, Population Health Programs, support services, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets contractual obligations to enable the care management team to achieve maximum clinical and financial outcomes.
• Uses evidenced-based approaches to increase employee and family activation and engagement in their own care. As appropriate to the population, partners with employee and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team and collaborates to develop a plan.
• Independently manages care management caseload and ensures timely completion of tasks and documentation related to regulatory and contractual requirements.
• Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient's status and determines priorities of patient care based on essential patient needs.
• Promote and optimize health for all employees using standardized health risk assessments and other screening tools deployed at the employer site.
• Perform health screenings to evaluate employees' health status, develop patient-centered goals, and provide education on wellness and chronic condition management.
• Coordinates patient information and communication between and among the employee/family, physicians, employer clinics, support services, EAP (if applicable), and other disciplines to ensure smooth transitions of care and referrals as indicated.
• Facilitates communications among patient/family, multi-disciplinary team, medical management team, community resources, and other disciplines, anticipating, identifying, evaluating, and acting to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the case management team to achieve maximum clinical and financial outcomes.
• Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
• Establishes and maintains effective communication and working relationships with physicians, leadership and operations in markets and sites supported by case management services. Responds to concerns and provides problem resolution as appropriate. Establishes relationships with payers to partner in the overall quality and efficiency of care provided to health plan members.
• Collaborates and communicates with external partners (employer, sales team, payers/third party administrators, brokers, etc.) and internal Advocate Aurora Health partners. Recognizes and resolves issues and understands when and how to escalate issues appropriately. Responsible for creating a positive service experience for the employer and employees by providing care management resulting in improved outcomes, addressing barriers to care, educating on health conditions, focusing on preventive care, and referrals to other areas as needed.
• Monitors and maintains accurate documentation of health/wellness management activities and outcomes as well as care management services.
• Collabo

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.

Education Required:

• Bachelor's Degree in Nursing or related field

Experience Required:

• Typically requires 5 years of experience in clinical nursing or 1-2 years in care management experience.

Knowledge, Skills & Abilities Required:

• Care Management Certification within 2 years of employment.
• Knowledge of Case Management and/or health coaching.
• Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
• Ability to demonstrate excellent oral, written and interpersonal skills.
• Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
• Ability to work productively and effectively that includes multiple changing priorities.
• Demonstrated ability to work well with physicians, employers, brokers, and other healthcare professionals in a direct and positive manner.
• Proficient computer/Microsoft-suite skills and previous EPIC EMR experience.
• Ability to work productively and effectively in a complex environment and handle multiple changing priorities.
• Demonstrated critical thinking, analytical problem solving and assessment skills.

Physical Requirements and Working Conditions:

• Position will require travel to the employer location(s) so there is exposure to road and weather conditions.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment; including usual hazards related to operating electrical equipment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.