Conducts assessments of patient/family needs for the highest risk patients or those patients at risk for poor outcomes.
Collaborates with health professionals across the continuum; formulates a documented plan of care that ensures continuity and goal-setting that equips individuals and their families to easily access resources and adopt healthy lifestyles.
Oversees care management functions and related tasks for a designated population.
Utilizes computer databases, documentation systems and develops/maintains accurate case records of all patients.
Promotes patient self-management, provides education about disease processes, and empowers patients and families to achieve maximum levels of wellness and independence.
Evaluates medical, rehab, psychosocial socioeconomic, psychological, and physical needs and makes referrals.
Provides medication management, including medication reconciliation during care transitions for the highest risk patients.
Identifies issues related to the healthcare system, transportation, financial, and/or psychological barriers and works collaboratively to problem solve, coordinate services, and to advocate for patients/families.
Identifies patient and/or clinic staff knowledge to understand deficits regarding specific programs.
Valid PA RN License
Master's Degree Nursing preferred
Experience with outpatient
Bilingual (English/Spanish) highly preferred
Prior electronic medical record experience
Obtain CACRN - Certified Ambulatory Care RN Ambulatory Care Manager within 3 years of hire or Care Coordination and Transition Management(CCCTM) or relevant certification relevant to role as approved by department leadership
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