As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step! JOB SUMMARY CCCS uses a holistic approach to medical management. The Personal Health Nurse (PHN) works within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means. The PHN performs the Personal Health Management process: assess the member; work with the member, family and physician to identify problems; establish goals and develop plans of care; coordinate services; educate members; and empower members to independently self-manage and to make knowledgeable health care decisions. The PHN works closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s) by performing functions of Personal Health Management as well as some functions of Utilization Management. Additionally, the PHN interfaces with clients and with CCCS client managers and are responsible for the medical management of designated client(s). All Medical Management Nurses practice within the scope of their licensures. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Manages accounts using the 4-Prong approach, meeting expected number of billable hours and using Conifer Value Based Care tools (CCOO) according to standard protocol. Documents accurate Status, Sub-status, Patient Severity, Medical Management Acuity Reviews daily calendar for new episodes and tasks due, prioritizes tasks on calendar Completes a Personal Health Management assessment incorporating analysis of clinical claim chart, discussions with the member and the physician's assessment and treatment plan Determines and documents member's goals, engages the member in the personal health management process. Develops an ongoing individualized plan of care with timeframes, reasonable and appropriate expected outcomes, specific planned interventions and member's goals. Follows through with interventions and documents outcomes in Current Clinical Status section of care plan Engages the PCP and treating physicians in the personal health management process, Collaborates with the member and PCP in development of an individualized plan of care Closes episodes as indicated, i.e. evaluates 'Impactability' among other indications for closure.