Director of Patient Engagement
Position Summary
The Director of Patient Engagement’s is responsible to act as a liaison and work collaboratively with health care staff, patients, families and community resources to optimize and provide a continuum of care of Medicare Beneficiaries in accordance with the organizations Missions and Values.  This will include developing and monitoring care management processes and support primary clinical teams with these efforts.  Working with the clinic leadership and medical director (lead physician) of the practice to develop this position to best serve the needs of the patient panel, case managers and the primary care teams

PRIMARY RESPONSIBILITIES AND DUTIES

  • Using CMS data, assists in the identification of at-risk patients who would benefit from care coordination.
  • Collaborates with Providers and their care coordinators in developing tools to improve the overall quality of care for patients, changing ineffective health care behaviors, identifying and overcoming barriers, and optimizing independence for patients..
  • Identifies and assists in implementing processes to reduce healthcare costs caused by emergency room use, hospital readmissions, duplication and gaps of care and improve the continuity of care across multiple care settings.
  • Acts as liaison between Brown Clinic and ACO promoting coordination of care to include the transfer of clinically relevant information, referral management, discharge planning and optimizing the use of community resources.
  • Follows Care Coordination Initiative policies for all ACO patients.
  • Develops relationships with community agencies to collaborate on better ways to coordinate care and help patients access community resources.
  • Participates in the Brown Clinic Quality Committee, developing agendas, maintaining minutes and coordinating with committee members in the development of tools for optimal patient outcomes.
  • Uses the Nursing Process of assessment, diagnosis, planning, implementation and evaluation in the patient’s plan of care, and communicates between multidisciplinary health care providers to eliminate fragmentation.
  • Collaborates with case managers addressing patient compliance issues; such as, medication adherence, therapy and other treatment progression.
  • Maintaining patient education processes and use of the patient portal for all Brown Clinic patients.
  • Participates in professional development activities and maintains RN capabilities to keep current with health care trends and practices.
  • Maintain an ongoing responsibility for assigned caseload.
  • Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.
  • Responsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls.
  • Participates in regular team meetings and peer review activities.  Participates in departmental and organizational committees as applicable. Promotes collaborative teamwork; able to work with peers in a team situation Collaborates with payer Case Managers for additional services when appropriate.
  • Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
  • Collaborates with physicians and other health care professionals regarding patient care.
  • Responds to and participates in Emergency situations.
  • Follows established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental and/or infection control standards
  • May train and guide other nursing and support staff engaged in clinical activities; may participate in research and related activities.
  • Performs miscellaneous job-related duties as assigned.
  • Works with IT staff member or department to coordinate the following:
    • EMR documentation to ensure use of searchable fields.
    • Efficient consult request communication.
    • Consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals.  

Qualifications
  • Education: Must have graduated with a minimum of an Associate’s Degree in Nursing; at least 1 year of experience that is directly related to the duties and responsibilities specified.
  • License/certification:  State of South Dakota Licensed Registered Nurse or current RN Licensure.  CPR Certified.  This position requires a valid driver’s license.
  • Experience:  RN must have at least two (2) years of broad clinical practice.  Experience in Discharge Planning, Case Management or homecare experience is preferred.  Quality Improvement activities preferred
  • Respect for and ability to follow Clinic’s Confidentiality Policy.