This role supports care management activities and value-based care initiatives for ambulatory services, specifically within the medical group. Performs all duties as assigned.
· Collaborate and participate in Baptist Medical Group’s care management and value-based care initiatives.
· Provide education to patients and caregivers regarding self-management of health care conditions that are appropriate based on language, cognitive abilities, literacy levels, patient preferences, and readiness for change.
· Facilitate the transition of patient care from inpatient settings such as hospitals, rehabilitation facilities, and skilled nursing facilities back to the patient’s home or community setting.
· Develop a comprehensive, collaborative care plan, based on the provider’s treatment plan.
· Assist patients with care coordination needs, including provider referrals, medication refills, appointments, and preventive screenings, as appropriate.
· Promote patient adherence to provider recommendations and treatment plan.
· Collaborate with providers to strengthen clinical documentation and support risk adjustment initiatives.
Minimum Required
· 3 years of nursing experience on current unit or in specialty area.
Preferred/Desired
· Experience with care coordination, case management, or utilization review processes.
Minimum Required
· BSN or equivalent years of nursing experience
Special Skills:
Minimum Required
Strong analytical and data management skills. Comfortable seeking direction and assistance from appropriate resources. Ability to communicate effectively verbally and in writing. Proficient ability to use a computer and electronic medical record. Comply with all
Baptist Memorial Health Care is one of the country’s largest not-for-profit health care systems and the largest provider of Medicaid in the region. Baptist offers a full continuum of care to communities throughout the Mid-South and consistently ranks among the top integrated health care networks in the country. The health care system comprises 24 affiliate hospitals in West Tennessee, Mississippi and East Arkansas; more than 5,400 affiliated physicians; Baptist Medical Group, a multispecialty physician group with more than 900 providers; home, hospice and psychiatric care; minor medical centers and clinics; a network of surgery, rehabilitation and other outpatient centers; and an education system highlighted by Baptist Health Sciences University (formerly Baptist College of Health Sciences). Baptist employs more than 21,000 people, and in fiscal year 2022 contributed more than $455 million in community benefit and uncompensated care to the communities it serves. For more information, please visit www.baptistonline.org or follow us on Facebook or Instagram.
