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Population Health Management provides case management services to the top 7% of BHN members in an effort to assist members with their health care needs and disease management with a goal of self-management, reduced hospital admissions and ED utilization, and increased compliance.
As a Health Partner working within our Population Health Management team, you will be working with members to address psycho-social barriers and social determinants that impact their ability to manage their health care, particularly during periods of transition from one level of care to another, e.g. from Emergency Room to home.
Monday-Friday; 9am to 5:30pm. Position will work from home and will travel throughout Central and Southern Arizona to preform in home assessments as need for critical care members
Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.
Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.
POSITION SUMMARY This position will be responsible to manage the rising risk members in the population. The Health Partner will be the main point of contact for members and providers across care settings. The aim is to better manage members in ambulatory setting providing a variety of support functions which contribute to the overall improvement in members' healthcare quality of life as well as efficient use of resources. Engages the appropriate resources within the multidisciplinary team to achieve optimal results for the patient, family, and care givers. This position provides comprehensive care coordination for patients as assigned. This position ensures adherence to the plan of care and develops, implements, monitors and documents the utilization of resources and progress of the member through their care, facilitating options and services to meet the members' health care needs.
CORE FUNCTIONS 1. Manages individual patients across the health care continuum (longitudinal support) to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Coach's members regularly regarding disease related symptom management. Advises members on lifestyle choices to improve prognosis and overall health. Provides patient monitoring, education, and supports patient care plan adherence.
2. Provides self-management support. Including but not limited to: using checklists and escalating as prescribed by protocols, promoting healthy behaviors, imparting problem-solving skills, and assisting with the emotional impact of chronic illness, providing regular follow up and encouraging people to be active participants in their care.
3. Applies the skills of motivational interviewing to promote the above lifestyle changes. Provides emotional support by showing interest, inquiring about emotional issues, showing compassion and teaching compassion.
4. Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements. Bridges gaps between the member and the clinical team including but not limited to following up with members, asking about needs and obstacles, and addressing health literacy, cultural issues and social-class barriers.
5. Meets and accompanies the patient and family to their initial appointments. Assists patients in navigating the health care system by connecting the client with resources, facilitating support and empowering the patient.
6. Educates internal members of the health care team on care management and managed care concepts. Facilitates integration of concepts into daily practice.
7. The position has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.
MINIMUM QUALIFICATIONS Requires a Master's Degree in Social Work or related degree with three years of experience directly related to care management in health plan/mgmt./quality.
Requires a Licensed Master Social Worker (LMSW) (equivalent*) or Licensed Clinical Social Worker (LCSW). An equivalent license applies to states that do not recognize an LMSW; therefore, the employee must possess a Master's Degree and be a Licensed Social Worker.
Must have highly developed interpersonal and critical thinking skills with the ability to prioritize needs rapidly. This position requires the ability to convey messages and thoughts clearly to a diverse audience, using both verbal and written mediums. Requires the ability to promote change among patients. Responsible, caring and respect for older persons. Requires the ability to coordinate information and activities, work under stress of deadlines and frequent interruptions, and to possess analytical problem solving skills. Must possess excellent organizational skills, as well as effective human relations and communication skills. Computer literacy and keyboarding skills is required. Must be proficient in the use of system office applications. Must possess a basic understanding of integrated clinical systems. Provide own transportation, required to possess a valid driver's license and be eligible for coverage under the company's auto insurance policy.
PREFERRED QUALIFICATIONS Certification with nationally recognized healthcare organization, such as CCM, preferred.
Additional related education and/or experience preferred.
DATE APPROVED 01/01/2017
Internal Number: R15907
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.