Full-time (80 hours biweekly) Weekdays, daytime hours 8 am to 4:30 pm Hybrid remote work options **General Summary** Coordinates and monitors the health needs of patients under value-based care risk arrangements, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. This position works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient's maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. This position ensures patient's cases are in compliance with regulatory guidelines. **Duties and Responsibilities** **Essential Functions:** + Utilizes Motivational Interviewing as a patient-centered technique to promote self-management of chronic conditions and improve long-term outcomes. + Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols. + Engages patients in home, primary care offices, and other community settings as appropriate. + Identifies, enrolls, and manages patients in Complex Care Management programs. + Conducts Transitions of Care and proactive outreach for high-risk patients and ensures appropriate follow-up via care management, or technology. + Develops, implements, and updates individualized care plans to optimize health outcomes and promote wellness. + Performs medication review and uses teach-back methods to confirm patient understanding and adherence. + Collaborates with PCPs, specialists, and hospitalists to coordinate and implement patient-centered care plans. + Initiates and tracks referrals to internal services and community resources to support care goals. + Provides resource management to ensure the right care is delivered at the right time and place, optimizing cost and experience. + Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care. + Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards. **Common Expectations:** + Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards. + Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. + Attends meetings as required. **Required for All Jobs:** + Performs other related duties as identified. + WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program. + WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information. The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. **Physical Demands:** + Standing - Occasionally + Walking - Occasionally + Sitting - Frequently + Reaching - Rarely + Talking - Frequently + Hearing - Frequently + Repetitive Motions - Occasionally + Eye/Hand/Foot Coordination - Occasionally **Working Environment:** + Occupational Hazards - Occasionally **Travel Requirements:** + Estimated Amount: 10% - Travel required. Makes home visits. **Qualifications** **Minimum Education:** + Associates Degree Required + Bachelors Degree Preferred **Work Experience:** + 3 years Nursing experience. Required + Experience in Care Management or Clinical Nursing specialty. Preferred **Licenses:** + Licensed Registered Nurse Upon Hire Required or + Registered Nurse Multi State License Upon Hire Required and + Basic Life Support Upon Hire Required **Courses and Training:** + Residency in service area. Upon Hire Preferred **Knowledge, Skills, and Abilities:** + Excellent communication and interpersonal skills. + Proficient in SBAR technique. + Ability to effectively present clinical information to the care team. + Proven organizational and motivational skills. + Ability to work cooperatively as part of a team. + Self-motivated and dependable. + Able to work independently. **Benefits Offered:** + Comprehensive health benefits + Flexible spending and health savings accounts + Retirement savings plan + Paid time off (PTO) + Short-term disability + Education assistance + Financial education and support, including DailyPay + Wellness and Wellbeing programs + Caregiver support via Wellthy + Childcare referral service via Wellthy For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org) (https://www.joinwellspan.org/benefits/) WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest. **Quality of Life** Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation. Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more - within an easy drive of major East Coast cities. York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000) WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.