Manage the Palliative Care program from design, planning, implementation, operation, and monitoring aligned with the NewPalex methodology, to improve the quality of life of patients and family members. Communicate with the payer care coordinators in the different regions to ensure continuity of care for the patients enrolled in the program, and a timely transition of care after hospital discharge. Also, will help navigate the patients through their different care providers (specialist, palliative care provider, primary care provider). 

Essential Job Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Registration and individual follow-up of members included in the Program. Monitoring, analysis and dissemination of quarterly, annual reports, etc. of management of the PC Program. Implement patient care workflows (and their verification). Assess program performance.        
• Following-up on patient enrollment by the palliative Care Program.
• Following up the results of the program at different levels at the level of your county (goals, indicators, defined strategies, etc.).
• Registration and individual follow-up of members included in the Program.
• Monitoring, analysis, and dissemination of quarterly, annual reports, etc. of management of the PC Program. Implement patient care workflows in collaboration with the patient care teams. Monitor adherence of workflows.
• Ensure program effectiveness.
• Ensure patients eligible for the program get enrolled, and that non-eligible patients get assigned to the required care team according to their needs. 
• Carrying out the search and reports of users eligible to the program according to the inclusion criteria. Monitoring and management of cases not accepted for referral to the program by specialists.
• Verification of compliance with the admission criteria of reported patients. Cancellation of presumptive marking of patients who do not meet criteria for the palliative care Program.
• Management of counter-referral to treating specialties through internal processing of patients who do not meet criteria.
• Weekly validation of the cases that enter the Program in relation to the level of care defined: in case of disagreement with the decision, must call the leader of the AC Team to discuss the case and reach an agreement.   
• Maximize program impact and ensure service availability.
• Ensure proper and timely transition of care working with the patient care team.
• Confirmatory marking of patients who, after initial evaluation by the palliative care Program, require referral to hospitalization of the external hospital network; taking into account that the health care providers included in the Palliative care Program responsible for admission must inform of this behavior via telephone call.
• Individual follow-up of patients who are in a hospital network external to the PC Program, establishing contact with the auditor assigned to the network. 
• Work with the clinical team to ensure continuity of care, prevent readmissions and adverse outcomes.
• Lead the defined committees and the Clinical and Administrative Palliative Care Boards. Develop the minutes of the different Boards and meetings with the health care providers and make it available to the national managers of the PC Program without affecting the governance of the Board by the Case Manager, and in case of affecting it, request collaboration from a third party to develop them. Follow up on the commitments agreed in the palliative care Boards.
• Participating in the scheduled activities, including providing input, showing results and preparing topics        
• Provide and receive input and feedback on the program performance. Strategic planning. Continuous improvement cycle.
• Review and record data related to patients who expire while on the Palliative Care Program.
• Individual study of cases of eligible patients who died outside the Program to identify the causes of their recruitment and propose improvement actions. Individual urgent study of patients who died in a non-active state, creating the necessary alerts so that this does not occur.     
• Optimize the identification of candidates to make sure the program reaches all patients requiring it.
• Monitor patient and family satisfaction and quality of life.     
• Keep track of the satisfaction and quality of life measurements of the patient and their family performed by palliative care teams. Compilation of patient testimonials in the Program. Ensure program quality.
• Monitor adverse events. Ensure program quality and safety.        
• Dissemination of the Program's inclusion criteria to specialists in the county, communicating with the specialists and giving them information of the program as well as engaging them as part of the care team. Increase the recruitment of patients to the Program.

Supervisory Responsibilities

This position has no supervisory responsibilities

Required Education

• BA/BS Degree or equivalent

Required Experience

• 3-5 years’ experience in clinical or community resource settings.
• This position requires a clinical background.

Required Licenses and Certifications

• N/A

Required Knowledge, Skills, and Abilities

• Evidence of essential leadership, communication, education, and counseling skills.
• Proficiency in communication technologies (email, cell phone, etc.). 
• Highly organized with the ability to keep accurate notes and records.
• Proficiency in medical terminology.  
• Clinical Case Evaluation.
• Patient and customer management.
• Any combination of education, training, and experience which demonstrates the ability to perform the duties and responsibilities as described including related work experience.

Preferred Qualifications

• RN license for the State of Florida      
• Care coordination. and/or case management experience is desirable.
• Preferred experience in Palliative Care programs.
• Experience with health IT systems and reports is desirable.    
• Local knowledge about and connections to community health care and social welfare resources are desirable.
• Advanced knowledge of Excel, and EHR preferred.

Supervisor Responsibilities:   This position has no supervisory responsibilities. 

Environmental Conditions:  

Inside:  Protection from weather conditions but not necessarily from temperature changes. The worker is subject to noise; there may be sufficient noise to cause the worker to shout in order to be heard above ambient noise level.

Physical Demands:       

While performing the duties of this job the employee is regularly required to work standing up, walk, use hands to operate tools and equipment and must be able to exert regularly up to 10 pounds of force, frequently exert 30 pounds of force and occasionally exert 50 pounds of force to constantly perform the essential job functions. The employee will be frequently required to reach with hands and arms, bend, balance, kneel, crouch, crawl, push, and pull. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.  

This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of the company. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.