Under general supervision, identification and intensive monitoring of high-risk patients, follow-up and clinical management of these patients. Coordinates care among providers and across continuum of care. Identifies high-risk patients in need of care management and pro-active outreach. Develops/reviews/updates medical, medication and transition management plans. Completes and analyzes medical, biopsychosocial support and self-management support assessments. Provides care coordination services to patients receiving clinical care management. Trains team members in care coordination and self-management support. Works with IT team on required reporting procedures and report development. Ensures monthly attestations are completed within Cyber access - and that all required reporting to the State of Missouri is accomplished.
Exceptional Employee and Customer Satisfaction: Creates an atmosphere of teamwork by contributing to opportunities to improve employee and customer satisfaction, including self-development, continuing education (personal and technical), and achieving department objectives and passport goals.
Exceptional Physician Satisfaction and Clinical Outcomes: Provides support, both expected and directed, and collaborates with physicians and multi-disciplinary care team(s) for Best Care/Best Results. Assures accuracy of data collection and reporting for Quality Initiatives. Contributes to the satisfaction of the medical staff by following physician orders and collaborating what he physicians to deliver best care.
Exceptional Financial Performance and Growth: Maintains accountability for maximizing revenue capture and growth while optimizing cost savings. Communicates opportunities for organizational growth and improvement.
Associate Degree or Diploma School Program
State of Missouri Nursing License;
1-3 years of experience
Medical acumen, experience working with similar populations, good communications skills, and ability to collaborate in a multidisciplinary environment.
SSM Health Cardinal Glennon Children's Hospital –
SSM Health Cardinal Glennon Children's Hospital is a not-for-profit, 190-bed inpatient and outpatient pediatric medical center in St. Louis, MO. We specialize in neonatology, cardiology, pediatric and fetal surgery, and cancer services. We care for children of all ages from St. Louis, Missouri, Illinois and from around the world. We also focus on the overall health of our communities in addition to the health of the children living in them.Our love for kids just keeps on growing!