Job Description Summary Manages the day-to-day activities of one or more of the Population Health specialized programs or products. Ensures the integration of evidence-based care practices into protocols, policies, consultation strategies, and continuous quality improvement initiatives. Supervises the team to ensure patients/members in the program meet eligibility requirements and appropriateness. Works in tandem with Health Plans to ensure appropriate services are put in place when criteria is met. Works under general supervision.
- Manages the day to day activities of specialized programs and/or products. Establishes workflows and protocol, assesses effectiveness, and makes recommendations for improvements, as needed.
- Acts as liaison for care management teams to ensure the program is meeting expected outcomes; implements changes as necessary.
- Initiates, leads, and/or participates in internal and external clinical care conferences. Acts as a resource for care managers in the coordinating care. Promotes staff understanding of tele-management process and its value for patients/members, medical providers, health care partners and the organization.Maintains excellent communication and relationships with home care/hospice teams and Health Plans.
- Assesses, educates, and improves patient/member knowledge of chronic disease, self-care management and identification of changes in health status, including appropriate responses and actions through individualized education and multifaceted interventions.
- Reviews VNSNY patient records for cases that were readmitted during an active home care episode. Leads and coordinates the root cause analysis of the readmission event in collaboration with VNSNY operations and helps to develop recommendations for quality improvement measures.
- Reviews productivity reports; analyzes trends and key findings in conjunction with management. Implements corrective measures to address any performance or operational issues.
- Conducts team audits on a routine basis in accordance with departmental policy.
- Assists staff in both in home care and health plans in the navigation of the patient/member, family, physician, and home care team through education, evaluation, and decision making, as needed.
- Oversees metric reporting and works with the Business Operations in the creation of weekly departmental KPI reports.
- Assists senior leadership with development of VNSNY client outcomes reporting and other analyses of clinical data and VNSNY quality reporting as needed.
- Performs all duties inherent in a managerial role. Ensures effective staff training, interviews candidates for employment, evaluates staff performance and conducts annual performance appraisal, and recommends hiring, promotions, salary actions, and terminations, as appropriate
- Participates in special projects and performs other duties as required.
Licensure: License and current registration to practice as a Registered Professional Nurse, in New York State required. Valid driver's license may be required, as determined by operational/regional needs.
Education: Bachelor’s degree in Nursing required. Master’s degree in Nursing or other health care related field preferred.
Certification: Population Care Coordination certification required within one year of job entry date. Care Management or Case Management certification required.
Experience: Minimum of five years of clinical nursing experience, with a minimum of one year in homecare or hospice for AIM, required. Experience in case management, administration or discharge planning experience in a hospital setting preferred. Training in population care coordination preferred. Exceptional customer service skills required. Demonstrated ability to engage clinical counterparts in collaborative discussions required. Strong follow up skills required, as well as the ability to manage multiple priorities. Proficiency in Microsoft Office Suite required. Knowledge of value based care models and managed care preferred. Hospice or palliative care experience preferred. Experience as a patient advocate preferred.
The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.