AdvantageCare Physicians (ACPNY) is one of the largest primary and specialty care practices in New York City.
With more than 35 medical offices and over half a million patients across all five boroughs and Long Island, ACPNY aspires to be a home for health for the communities we serve.
This vision is accomplished through a “whole you” care approach that recognizes the physical, mental, and lifestyle factors that impact a patient’s health.
When our teams of providers, nurses, and specialists work together, we can get patients in sooner, answer their questions in real time, and give them the support they need to achieve their health goals.
ACPNY is also driven by a commitment to diversity, an unyielding desire to deliver high-quality care, and community-focused collaboration.
By integrating these behaviors into our day-to-day operations, ACPNY strives to always create healthier futures for our patients.
BronxDocs medical offices are affiliates of AdvantageCare Physicians.
Responsibilities Provides in person and or telephonic Case Management Services to identified high risk PHSO (Population Health Service Organization) patients within the community including but not limited to Physician Practices and Neighborhood Care Centers Consults with patients on their medications and durable medical equipment, reviewing patient care plans, addressing home care needs, and connecting patients to community resources Collaborates with primary care physicians and other providers to ensure there are no gaps in care; the goal to improve health care outcomes and appropriate and timely utilization of services across the continuum of care Collaborates with patients, providers, and caregivers to ensure positive care outcomes during care transitions Provides patient education to assist with self-management, educate on disease processes, and encourage healthy lifestyle changes.
Includes patient and family as appropriate.
Engages actively with the primary care provider (PCP) /designee Engages with the patient in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes Assesses the needs of patients and aligns them with the appropriate member of the care team (wellness team, registered dietitian, social worker) and develops a patient-centric care plan Monitors, documents, and tracks care team performance to ensure patients are engaged in a timely fashion and that performance metrics (Admits, ER utilization etc.) meet or exceed established thresholds Provides ongoing monitoring, evaluation, support, and guidance to the coordination of the patient’s health care Ensures that discharged patients receive the necessary services and resources, including medication reconciliation and coordinating services such as home health and DME, as needed Works collaboratively with medical office team members with the goal of maintaining team performance and high morale Qualifications Current, unencumbered New York State Registered Nurse license CCM (Case Management) certification preferred Bachelor’s degree preferred Minimum 4
– 6 years’ RN clinical experience Excellent verbal and written communication skills, including phone etiquette Strong working knowledge of Microsoft Office applications including proficiency in MS Word and Excel Proficiency in the use of EMR (Electronic Medical Record) systems Ability to effectively manage a team of highly complex patients Ability to support an integrated care model tapping into appropriate resources both internally and external to the organization Additional Information Requisition ID: 220KT