Description
Summary :
Provides care under the direct supervision of thePopulation Health Director of Care Management or Nurse Managerutilizing physician approved patient protocols according toestablished standards and best practice guidelines.
Facilitates thecommunication between patient / caregiver, physician and theoutpatient care team to optimize health and wellness, reduceinpatient admission, reduce re-admissions and improve medicalstability in the patient population served.
Works collaborativelywith Nurse Navigators to manage medical stability in patients withhigh risk disease management with complex comorbidconditions.
- Manages patients withidentified gaps in care in collaboration with the Health CareTeam.
- Works in collaboration with the PCMHTeam in the design, implementation and evaluation of the PMH modelas applicable.
- Works proactively to coordinatepreventative / follow-up care for all patients receiving care fromparticipating providers.
- Reviews patientmedical record to identify care gaps.
- Schedules needed preventative services using evidenced basedPhysician approved protocols and documents theencounter.
- Fosters a Team approach by workingcollaboratively with the member, family, PCP and other members ofthe healthcare team to ensure coordination ofservices.
- Assists Nurse Navigators’ inperforming transition of care outreach to discharged patients toschedule return visit with the PCP perguidelines.
- Employs knowledge of evidencedbased guidelines to effectively communicate the importance ofrecommended procedures and testing.
- Facilitates a collaborative approach with care team foridentification of and closure of care gaps.
- Utilizes educational and behavioral change strategies to promotepatient collaboration with the care team.
- Incorporates excellent written, verbal and listening communicationskills, positive relationship building skills and problem solvinginto patient care coordination practice.
- Performs duties as required or assigned for specific operationalpurposes for which they are qualified toperform.
- Maintains all professional CEU’s incompliance with State and Regulatoryrequirements.
- Maintains confidentiality in allareas at all times.
Requirements :
LVN License in state of employment orcompact
Work Type : Full Time
Full Time
EEO is the law -click below for more information :
https : / / www.eeoc.gov / sites / default / files / 2023-06 / 22-088 EEOC KnowYourRights6.12ScreenRdr.pdf
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