Job Description

Description Summary: Provides care under the direct supervision of the Population Health Director of Care Management or Nurse Manager utilizing physician approved patient protocols according to established standards and best practice guidelines. Facilitates the communication between patient/caregiver, physician and the outpatient care team to optimize health and wellness, reduce inpatient admission, reduce re-admissions and improve medical stability in the patient population served. Works collaboratively with Nurse Navigators to manage medical stability in patients with high risk disease management with complex comorbid conditions. Responsibilities: Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team. Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable. Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers. Reviews patient medical record to identify care gaps. Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter. Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services. Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines. Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing. Facilitates a collaborative approach with care team for identification of and closure of care gaps. Utilizes educational and behavioral change strategies to promote patient collaboration with the care team. Incorporates excellent written, verbal and listening communication skills, positive relationship building skills and problem solving into patient care coordination practice. Performs duties as required or assigned for specific operational purposes for which they are qualified to perform. Maintains all professional CEU’s in compliance with State and Regulatory requirements. Maintains confidentiality in all areas at all times. Requirements: LVN License in state of employment or compact Work Schedule: 8AM - 5PM Monday-Friday Work Type: Full Time

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