Job Summary: The focus of the Ambulatory Quality Nurse (AQN) is one of Population Management & Care Coordination in the practice setting. The AQN will help the providers manage and develop care plans for the high risk patients; they will seek to identify and eliminate barriers to the patient care and help to clarify & support specific patient goals. The AQN will utilize data to drive the delivery of proactive, coordinated care and services and help to manage the transitions of care. The AQN will ensure educational resources are available for the patients as well as self-empowerment tools. They will plan and deliver individual and group education sessions and identify and encourage the utilization of community resources. The AQN will help to guide the Care Team to increase the number of high risk patients that receive preventative care. The AQN will provide guidance to support the PCMH standards, guide and support performance improvement activities and seek to increase quality outcomes & improve the overall patient experience.
Summary of Accountabilities:
Collaborates with the provider & care team to improve quality metrics for ACO, Meaningful Use , CQM, & PSRS and quality programs to increase the number of pts. Who receive appropriate preventative and chronic condition care Conducts Transitional Care management for patients post discharge patients ensuring that the patients are stabilized in the community; initiates medication reconciliation coordinates referrals & ensures post discharge visits. Establish personal relationships with PCMH High Risk pts. to encourage Pt. empowerment utilization of self-management tools , adherence to goals and plan developed by the provider Supports and mentors the Care team regarding the use of evidence based guidelines Will conduct calls or face to face sessions with PCMH high risk pts. related to abnormal labs, medication adherence; will seek to convert patients to generic medications Identifies & helps to eliminate barriers for the high risk patients Identifies and reaches out to high Risk pt. who have not visited the practice Help provider develop a plan of care related to high utilizers of the ER or hospital Identifies and provides educational tools for the PCMH chronic condition & unhealthy behaviors with the Seeks to manage chronic conditions so to reduce hospital stays and ER visits Conducts or arranges educational sessions for the High risk pts. and mentors staff to help with education Helps to identify and mentors the team regarding the availability of Community resources including those needed for behavioral health or end of life support Empowers the Care team to help support PCMH standards and implement processes that are efficient and effective to improvement and support quality patient care Utilizes Pt. experience data to help identify areas of opportunity for improvement Champions the PI initiatives and seeks to improvement the overall care and pt. experience Identifies policies for development ; participates in the creation of policies as assigned by VP Maintains statistics, data & reports as needed Responsible to help with the PCMH application and survey tool ; mentors the team to ensure appropriately documentation is maintained & established Attends meetings, educational programs or participates in committees as assigned Manages and reports data to the VP of quality as requested Participates in the Quality Team orientation Ensures Transitional coding is utilized and managed appropriately.
Other duties as assigned
Minimum Degree Required and Experience Required:
- Certified Case Management (CCM) certification preferred, BSN or Masters Degree.
- Requires an active NJ Registered Nurse License.
- Basic PC skills (MS Word / Excel) ability to use and manipulate excel files.
- Data analysis skills.
- Highly developed interpersonal skills including motivational interviewing skills, in order to interact effectively and motivate patients to change behavior when necessary.
- Requires working knowledge of principles of utilization management.
- Requires working knowledge of case/care management principles.
- Requires knowledge of health care contracts and benefit eligibility requirements.
- Requires knowledge of hospital structures and payment systems.
- Experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, or managed health plan.
- 5 to 8 years of direct patient care experience required.
- Familiarity with community resources and social service resources to assist patients with social needs.
- Persuasive interpersonal skills required.
- Demonstrated ability to influence others while motivating them to change.
- Reasoning and problem solving ability.
- Multitasking and prioritization working in a high volume environment with little supervision.
- Working independently as well as in a team environment.
- Function within the standards of practice for case management.
- Exercise sound judgment.
- Take initiative in finding solutions to difficult and/or sensitive problems.
- Interpret clinical reports
- Assess patient needs and develop a plan of action to address needs in collaboration with the primary care physician.
- Ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.
- Strong analytical skills.
- Travel may be required.
- Participate in meetings.