How will this role have an impact?
While there are many goals of this program, the overarching goal is to improve the quality of life for our members by reducing overall utilization and preventing unnecessary hospitalizations and emergency room visits. Signify Health is focused on improving the quality of life for health plan members through effective care coordination and best in class care management. Our Complex Care Management program services our clients' dual eligible members residing in long term care facilities. The Complex Care Management Nurse Practitioner role, while autonomous, functions within a multidisciplinary team to positively impact member healthcare outcomes.
This role will report to our CCM Clinical Network Manager
What will you do?
- Conduct routine in-person follow-up visits for members residing in long term care facilities
- Communicate regularly with members, appropriate caregivers, PCPs & other medical staff based on each member's identified needs
- Monitor the quality of member's care, partner with the member's Primary Care Provider and ancillary care team to quickly identify changes in condition or gaps in care, and facilitate care coordination and adjustment to the member's care plan
- Partner with Signify Health, the health plan and providers to help coordinate both internal and external resources to meet the member's identified needs
- Enroll newly identified candidates into the Complex Care Management program, performing and initial Health Risk Evaluation and developing a plan of care
- Quickly respond to any urgent/emergent conditions and ensure that members receive the appropriate care in the appropriate setting, prescribing and treating as appropriate and communicating closely with PCP to provide timely updates on members' status
- Perform timely post-hospitalization evaluations of members upon their return to long term care facility, identifying readmission risks, and developing a risk mitigation plan
- Perform repatriation assessments and facilitate discussions between the health plan, facility, and member as appropriate
- Provide routine and ongoing education to members, caregivers, and facility staff as needed
- Engage in end of life care planning as needed, facilitating palliative care and Hospice discussions with members and family members as needed
- Engage in client Interdisciplinary care team meetings, internal clinical office hours, and other meeting venues as necessary
- Uphold Signify Health core values of Compassion, Accountability, Inclusive, and Adaptability
- Assist with improvement to work processes and commit to a focus on continuous improvement of workflow processes and procedures
- Attend training sessions and participate on committees as requested
- Perform other related duties and responsibilities as assigned
We are looking for someone with:
- Active APRN license in good standing and without restrictions
- Minimum of 1 year clinical APRN experience preferred, but will also consider actively licensed new APRN graduates with strong prior clinical background in Geriatrics, Adult Medicine, Long-Term Care, Home Health or ED/ICU experience
- Minimum of 2 years' clinical experience working with complex adult populations (either as NP or RN)
- Strong knowledge of various chronic medical conditions along with the associated routine lab monitoring, diagnostic, and treatment options as well as commonly prescribed medications for those conditions
- Ability to quickly develop rapport and establish positive working relationships with members, nursing home facility staff, PCPs, specialty providers and professional colleagues
- Understand and be able to apply principles of Care Management and individualized care planning
- Ability to work in fast-paced environment and adapt well to frequent change
- Strong critical thinking skills
- Strong organizational skills and the ability to prioritize
- Ability to effectively present information and respond to questions from members, providers, team members and managers
- Experience in utilization review and/or risk management a plus
- Previous Complex Care Management (as an NP or RN) experience a plus
- Bi or multilingual ability a plus
Signify Health is helping build the healthcare system we all want to experience by transforming the home into the healthcare hub. We coordinate care holistically across individuals' clinical, social, and behavioral needs so they can enjoy more healthy days at home. By building strong connections to primary care providers and community resources, we're able to close critical care and social gaps, as well as manage risk for individuals who need help the most. This leads to better outcomes and a better experience for everyone involved.
Our high-performance networks are powered by more than 9,000 mobile doctors and nurses covering every county in the U.S., 3,500 healthcare providers and facilities in value-based arrangements, and hundreds of community-based organizations. Signify's intelligent technology and decision-support services enable these resources to radically simplify care coordination for more than 1.5 million individuals each year while helping payers and providers more effectively implement value-based care programs.
To learn more about how we're driving outcomes and making healthcare work better, please visit us at .