Looking to use your nursing skills in more of an administrative capacity with full time hours, M-F, days in a healthcare system that makes the patients and YOU the #1 priority? Thompson Health is the place for you!

Main Function:

Work in conjunction with a care team to identify and proactively manage the care needs of high risk patients within the primary care practice setting Provides assessment, care coordination, advocacy and coaching for identified patients that are at risk for hospital admissions or emergency room visits. Uses established Finger Lakes Health System Agency (FLHSA) CMMI grant criteria to identify at-risk patients  Determines the drivers of risk in conjunction with the patient, family, physician and ancillary health care providers Measures the impact of care coordination interventions, and regularly re-assesses the patient’s risk for incurring adverse health outcomes

Required Job Specific Competencies:

Ability to develop and support a practice based care management model by providing on-site and telephonic services i.e. wellness, health coaching, self-management techniques, disease management and case management including coordination with community services per FLHSA standards Identifies high risk patients needing care management services Provides education, support and outreach to patients over the phone and in person ensuring all aspects of FLHSA programs are met for family practices Interacts closely with clinical teams to identify care gaps and improve clinical outcomes for patients with chronic conditions such as diabetes Active support for Thompson Practices quality programs, including PCMH and Diabetes Recognition Program Scans the medical literature routinely for updates on clinical practice guidelines, new developments in the management of chronic diseases and communicates and disseminates information to staff Complies with all required Joint Commission, state and federal regulations

Qualifications: (Licenses, Certifications)

Current New York State Registered Nurse license required BLS certification Proficient in the use of Electronic Medical Records (EMR); Ability to create reports on own and interface with EMR vendor to develop reports where none currently exist Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint) Effective oral and written communication skills Patient Centered Medical Home and Diabetes Recognition Program knowledge and experience a plus

Experience:

Preferred Experience: 3- 5 years of clinical nursing or social work experience, preferably with 3-5 years of community health experience, with the adult population Electronic Medical Record experience required Experience with database entry and reporting preferred Care Management experience preferred

Education:

 Valid NY state nursing license  A graduate of an approved school of nursing   BSN required

Position Pay Range: $70,000-88,000 per year

Starting Pay: Based on experience

Thompson Health is an EOE encouraging women, minorities, individuals with disabilities and veterans to apply