Trillium Health, a Federally Qualified Health Center Look-Alike, is a community health center offering access to affordable care for all, with a special focus on meeting the needs of LGBTQ people, communities of color, and underserved populations.

Nationally recognized for outstanding patient-centered care, the team at Trillium Health provides a wealth of knowledge and experience. Our expansive array of services, including testing and treatment, laboratory services, primary and specialty care, and an on-site pharmacy, makes it easier for patients and clients to receive the complete care they need, all in one place.

Our authentic commitment to diversity and inclusion is evidenced through our hiring practices, our employee programs, and our compassion for everyone we serve. Based in downtown Rochester, with satellite locations in Bath and Geneva, and MOCHA centers in Buffalo and Rochester, Trillium is deeply invested in building community. We proudly sponsor many other nonprofit organizations throughout the area and participate in a wide range of community events.

Trillium’s employee-centered company culture and exceptional benefits have contributed to impressive growth in recent years, raising our staff total to more than 250. We hope you will consider joining us on this upward path and becoming a part of the Trillium Health family.

We are currently recruiting for a RN Complex Care Manager.

The RN Complex Care Manager is a member of an interdisciplinary team made up of clients, their providers and support network, and the Priority Care Team. The RN Care Manager:

• Establishes person‐to‐person relationships
• Utilizes evidence based clinical guidelines
• Adheres to established care management standards of care: screen, assess, prioritize risk, plan and facilitate
• Takes a longitudinal view (weeks, months, years) and works toward problem solving and self‐ management skills for the client
• Works primarily with the client while incorporating the family, clinicians, and other team members into the development of a patient centered action plan

Coordinates care with other members of the health care team for optimal client outcomes

• Works as a member of all the Pod Teams to ensure effective communication and coordination for all complex, high risk patients

• Attends department and other meetings as needed
• Supports client care needs by
• responding to physician/provider referrals,
• performing and documenting assessments and nursing interventions
• answering general healthcare questions,
• discussing and explaining results of screenings,
• coordinating the delivery of care and
• promoting client self‐management skills

Care Management Systems Responsibilities, Patient/Client Navigation & Care Management:

• Manage Trillium Health’s high-risk patient data
  • Coordinate systems for identifying high risk patients through EHR, internal referrals and MCO provided patient lists
  • Collaborate with Information Technology for registry functionality and Business Intelligence for high risk patient reports.
• In collaboration with IT, develop a tracking system for patient care coordination and care management across the continuum, including care transitions, primary and specialty
• Conducts assessments of patient needs in order to evaluate eligibility for services
• Provide person-centered, quality driven, care management to eligible patients per agency policies and procedures
• Assist in the reduction of avoidable health care costs specifically; (1) preventable hospital admissions/readmissions and (2) avoidable emergency room visits by providing timely post discharge follow-up and improving patient outcomes
• Build relationships with the patient and all members of the care team to support continuity of care and promote health outcomes
• Coordinate and participate in regular care plan review meetings for high need, high acuity patients/clients being followed in clinic
• Accountable for engaging and retaining patients in care
• Document each patient focused interaction comprehensively and concisely, in accordance with agency standards
• Promote patient access into internal agency services including, but not limited to: Health Home, Grant Case Management, support groups, behavioral wellness, medical care, supportive services and Community Health Initiative Services

Direct Patient Care Responsibilities:

• Conduct comprehensive assessment of patients’ physical, mental, and psychosocial needs
• Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ED utilization
• Utilize evidence-based behavioral strategies such as Motivational Interviewing, Shared Decision Making, and Coaching for Activation to help patients adopt healthy behaviors and improve self-care in chronic disease management.
• Promote self-management SMART
• Assist patients in navigating the health care system. Coordinate Specialty care, follow-up on test results and other care coordination
• Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of ED visit notification
• Integrate with Trillium Health’s Health Home Care Management program and Supportive Services and patient care plans
• Partner with external care management programs to coordinate care
• Ongoing evaluation and documentation of patient progress/ risk status Document in EHR; communicate with care teams
• Document in EHR

Miscellaneous

• Requires valid NYS driver’s license and insured dependable car to use for travelling to offsite locations to conduct business supporting program activities.
• Requires the ability and commitment to respect and support inclusiveness and diversity including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc.
• Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.
• Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
• Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans.
• Adhere to all government and funder regulations.
• Performs other duties as assigned.

Qualifications

• NYS RN or greater clinical license required
• 3-5 years of direct clinical experience required
• Experience in care management, disease management, home health care nursing, hospital nursing or intensive outpatient settings, and education and self-management support preferred
• Familiarity with the Patient Activation Measure (PAM) preferred
• Skills
  • Comprehensive nursing assessment, problem identification and prioritization, and care plan development
  • Patient centered disease management
  • Screening for developmental issues, depression, other psychological conditions, and frailty.
  • Clinical system design and development
  • Project management
  • Behavioral strategies including motivational interviewing and self-management support
  • Relationship building with patients, staff, and providers
  • Documentation in an EHR
  • Computer skills including Excel, Word, Outlook and PowerPoint
• Organized and resourceful self-starter; strong ability to work in a team
• Excellent written, oral and interpersonal communication skills

Trillium Health offers employment to all employees & applicants. No person shall be discriminated against in employment on the basis of race, age, color, marital status, religion, creed, sex, sexual orientation, gender identity or expression, national origin or ancestry, disability, veteran status, status as a domestic violence victim, genetic condition or predisposition, or any other characteristic protected by law.

Apply online at https://www.trilliumhealth.org/en/291/careers