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Department
VALLEY PARTNERS LLC - 838376
Worker Sub Type
Regular
Work Shift
First Shift (United States of America)
Pay Grade
135
Job Description
Service oriented, well versed in quality measures, and familiar with approaches for reviewing charts to identify and address quality measure gap closure through care coordination.
Collaborates with providers and clinic staff to identify and prioritize patients appropriate for care coordination services, utilizing care coordination criteria. Advance quality goals and facilitate the sharing of necessary data and information to support ongoing quality improvement.
Collaborates with Performance Optimization Team to address care gaps, focused on improving quality measures including HEIDS, MIPS, and Stars.
Knowledge of current federal, state, and local programs as well as their eligibility requirements and application process in order to pro-actively connect patients with appropriate resources.
Develops care coordination plan and goals mutually agreed upon by patient/family. Utilize motivational interviewing techniques and assist patient in meeting action-oriented goals and objectives. Emphasize the importance of preventative care and provide education on importance of obtaining preventative screenings. Address Social Determinants of Health and barriers to obtaining care.
Interacts professionally with patient/family to achieve maximum levels of wellness and independence.
Performs initial calls for patients recently discharged from the hospital or Emergency Room who are considered high risk for readmission. Ensure that the patient has attended follow up appointments as scheduled and is adherent to medications. Provide patient with education regarding hospital diagnosis. Identify patients who have had a change in condition and escalate care to provider or EMS services as appropriate.
Serve as liaison to providers, patients and families for coordination of services.
Review utilization and quality reports routinely, scan for gaps in care and identify patients needing the additional support of care management.
Participates in regular team meetings. Participates in departmental and organizational committees as applicable. Participates in the orientation of new personnel. Precepts and acts as a mentor to peers. Promotes collaborative teamwork.
Serve as liaison between Performance Optimization team, provider practices, and patients to implement initiatives that improve access to care and the quality of services provided.
Meet with Clinical Manager, Population Health and Manager for Performance Optimization on a regular basis to provide patient updates, identify issues, and develop strategies for resolution.
Attends payer meetings as needed to stay current on payer program details and requirements to obtain shared savings, PMPM, and STARS bonuses. Stay abreast of payer resources, programs and education available to patients and providers, and make recommendations to Performance Optimization team and Population Health team on implementation of such resources to improve overall scoring.
Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing. Ensures documentation meets current standards and policies.
Attends conferences, workshops, and complete continuing education as assigned.
Education
Bachelor's degree in Nursing (BSN) is required.
Experience
3 years relevant nursing experience including a minimum of 2 years' nursing case management experience, preferably with older patients, is preferred.
Navigation experience in outpatient setting preferred.
Home Health/Public Health is preferred.
Certification & Licensure
Registered Nurse license is required, state applicable based on state of work assignment. Based on primary state of residency and in accordance with current West Virginia or Virginia Board of Nursing Regulations, must be licensed or eligible to practice pending licensure as a Registered Nurse in the West Virginia or the Commonwealth of Virginia with either a multi-state license, under the Nurse Licensure Compact OR Single-state license, valid in West Virginia or Virginia only.
BLS Certification (Basic Life Support) - American Heart Healthcare Provider' (HCP) - AHA approved is required. New hires must have American Heart Association (AHA) appropriate certification prior to completion of orientation.
Qualifications
Knowledgeable in stages of human growth and development for adult and geriatric populations.
Skills in interpersonal relationships, clinical assessment, group process and high levels of verbal and written communication.
Ability to interact with other professionals as part of a multidisciplinary team, displaying good judgment and decision-making skills.
Skills in interpersonal relationships, clinical assessment, group process.
Self-directed with the proven ability to work independently essential.
Knowledge of funding, resources, clinical standards and outcomes for population.
Benefits
At Valley Health, we believe everyone is a caregiver, and our goal is to create an environment where our caregivers thrive physically, financially, and emotionally. In addition to a competitive salary, our most popular benefits for full-time employees include:
A Zero-Deductible Health Plan
Dental and vision insurance
Generous Paid Time Off
Tuition Assistance
Retirement Savings Match
A Robust Employee Assistance Program to help with many aspects of emotional wellbeing
Membership to Healthy U: An Incentive-Based Wellness Program
Valley Health also offers a health savings account & flexible spending account for childcare, life insurance, short-term and long-term disability, and professional development. In addition, several perks come with working for the largest employer in the region, such as discounts to on-campus dining, and more.
To see the full scale of what we offer, visit .
Date Posted: 06 May 2025
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