Personal Health Nurse - Remote

JOB SUMMARY CCCS uses a holistic approach to medical management. The Personal Health Nurse (PHN) works within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost-effective means. The PHN performs the Personal Health Management process: assess the member; work with the member, family and physician to identify problems; establish goals and develop plans of care; coordinate services; educate members; and empower members to independently self-manage and to make knowledgeable health care decisions. The PHN works closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s) by performing functions of Personal Health Management as well as some functions of Utilization Management. Additionally, the PHN interfaces with clients and with CCCS client managers and are responsible for the medical management of designated client(s). All Medical Management Nurses practice within the scope of their licensures. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Manages accounts using the 4-Prong approach, meeting expected number of billable hours and using Conifer Value Based Care tools ( CCOO) according to standard protocol. Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity Reviews daily calendar for new episodes and tasks due, prioritizes tasks on calendar Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the member and the physician’s assessment and treatment plan Determines and documents member’s goals, engages the member in the personal health management process. Develops an ongoing individualized plan of care with timeframes, reasonable and appropriate expected outcomes, specific planned interventions and member’s goals. Follows through with interventions and documents outcomes in Current Clin