This list contains only the countries for which job offers have been published in the selected language (e.g., in the French version, only job offers written in French are displayed, and in the English version, only those in English).
This position manages clinical aspects of patient centered care including management of chronic conditions. This position works with the interdisciplinary medical team in the provision of patient care and development of program goals and initiatives.
Job Responsibility:
Coordinates medical care of patients identified as high risk by health risk assessment/appraisal or by physician clinical determination
Assumes coordination role at the point of service through targeted outreach and follow-up
Assists in developing and implementing care plans for medically complex patients
Identifies barriers to a successful care management path
Identifies patient groups with chronic diseases
Assists in developing and implementing population-based strategies to close gaps in medical care
Identifies resources for patient self-management skills
Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan
Participates in program development by assisting with planning short-range and long-range program goals for chronic disease management
Assists with the development of current evidence based protocols, policies, work flow/flow sheets, guidelines, etc. related to the provision of care within the medical home model
Participates in committees as assigned
Interacts effectively with physicians, home care team, patients, and their caregivers
Accountable for patient triage
Keeps abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature and maintaining professional contacts in the community
Other duties as assigned
Requirements:
Bachelor's degree in Nursing or health related field and 3 years of relevant experience required
Or equivalent combination of education and experience
Ambulatory care experience in community health, care management, disease management, quality improvement and/or management experience preferred
RN - Registered Nurse - State Licensure and/or Compact State Licensure upon hire required