Overview of the Role :
Assists patients to reach optimal function and health in community-based settings. Collaborates with health team members to ensure safe, high quality and cost-effective care.
Essential Job Duties :
Contacts patients telephonically and in person at community-based medical practices to provide care management activities.
Refer and connect patients to organizations that support identified health care needs.
Address and facilitate patient referrals to address gaps in care.
Assess patients’ knowledge of current health status and support informed decision-
making.
Encourage confidence in patients’ abilities to regain / optimize their own health.
Collaborate with inter-departmental teams and medical practice staff to facilitate program objectives and goals.
Qualifications
- ADN or Diploma in Nursing with 5+ years of nursing experience or BSN / BAN 3+ years of experience in nursing
- 2+ years of population health or care coordination experience
Active unrestricted license in CT or able to obtain (if needed)
Strong computer and EHR skills and expertise
Preferred experience with Medicare aged patients in a value-based program
Preferred experience educating and engaging patients
Experience working in an outpatient medical office
Ability to travel to and from care centers to meet with patients and providers
Must comply with all HIPAA rules and regulations
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