Overview

Job Summary

This role supports care coordination activities within ambulatory services; specifically for the medical group. Performs all duties as assigned.

Responsibilities

Collaborate in overseeing the practice's care coordination initiatives.
Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
Develops a comprehensive, collaborative care plan, based on provider treatment plan and patient/family goals for recently discharged patients and promote adherence to physician/provider recommendations and instructions.
Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.
Identifies and implement cost effective problem solving, process improvement, risk assessment and the reduction of waste.
Completed assigned goals.

Specifications

Experience

Minimum Required

Preferred/Desired

Education

Minimum Required

Preferred/Desired

Training

Minimum Required

Preferred/Desired

Special Skills

Minimum Required

Strong analytical and data management skills. comfortable seeking direction and assistance from appropriate resources. Ability to communicate effectively verbally and in writing. Proficient ability to use a computer and electronic medical record. Comply with all HIPAA regulations - maintain patient, team member and employer confidentiality. Customer Service Oriented, friendly, cheerful, helpful and cognizant of patient needs. Ability to work independently and exercise clinical judgment in interactions with providers, payers, patients and their families. Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.

Preferred/Desired

Licensure

Minimum Required

Registered Nurse (RN) Nurse-Navigator