Description

JOB SUMMARY

Conifer uses a holistic approach to medical management. The Sr. Personal Health Nurse (PHN) works within a team to move the participant through the continuum of medical management with the goals of facilitating quality health care through the most cost-effective means. The Sr. PHN performs the Personal Health Management process: assess the participant; work with the participant, family, and physician to identify problems; establish goals and develop plans of care; coordinate services; educate participants; and empower participants to independently self-manage and to make knowledgeable health care decisions. The Sr. 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 Sr. PHN interfaces with clients and with Conifer account managers and are responsible for the medical management of designated account(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-Pronged 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 participant and the physician’s assessment and treatment plan
• Determines and documents participant’s goals, engages the participant in the personal health management process. Develops an ongoing individualized plan of care with timeframes reasonable and appropriate expected outcomes, specific planned interventions and participant’s goals. Follows through with interventions and documents outcomes in Current Clinical Status section of care plan. Documents each component thoroughly: treatment plan, diagnoses, cost savings
• Engages the PCP and treating physicians in the personal health management process, Collaborates with the participant and PCP in development of an individualized plan of care
• Closes episodes as indicated, i.e. evaluates “Impactability” among other indications for closure.
• Assesses and documents clinical and behavioral outcomes, Consults with IMMS Medical Director on issues of concern about participant treatment plans, Refers all participants who have a patient severity of “high” to case management, Triggers and reviews participants,
• Identifies liability issues associated with the performance of medical management, Identifies and documents financial outcomes according to Conifer’s ’s standards
• Participates in account meetings, Reports any account issues or questions to the TL on the account
• In collaboration with the TL, identifies and brainstorms areas that may be improved, Acts as a resource to nurses on the team

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Functions independently
• Understanding of Conifer’s holistic approach to medical management
• Understanding of the client’s (customer’s) perspective and needs
• Understanding of legislative acts, such as the ADA
• Adheres to of the CMSA Standards of Practice, Adheres to CMSA Standards of Practice and Professional Code of Ethics
• Advocates for participant to obtain quality health care
• Understands purpose of URAC knows how to access the standards
• Uses Milliman Care Guidelines
• Competency with Conifers Web-based products as they relate to case management, including referrals, Clinical Claims Chart, EBM, Risk Stratification, etc.
• Knows how to access and uses the Summary Plan Descriptions (SPD)
• Competency in Word
• Competency using email, attachments
• Excellent verbal communication skills with the ability to communicate with participants and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, account managers, brokers, customer service staff, Conifer executive management, other Conifer Medical Management nurses, hospital utilization review nurses, etc.
• Excellent written communication skills with the ability to write in a professional, business manner
• Ability to analyze and resolve complex problems
• Excellent organizational, prioritization, and time management skills
• Ability and willingness to function both independently and as part of a team

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Bachelor degree in a health related field
• Five (5) years of UM/CM experience
• Three to five (3-5) years of diverse clinical experience required
• CCM preferred

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• RN (Registered Nurse) license required
• Current active professional license in the state of residence
• Eligibility for unrestricted professional licenses in all states

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone
• Ability to travel
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

TRAVEL

• Approximately 5% travel may be required

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

• Pay: $72,509.00 - $108,763.00 annually. Compensation depends on location, qualifications, and experience.
• Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

Conifer offers the following benefits, subject to employment status:

• Medical, dental, vision, disability, life, and business travel insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.