Description:

The RN-CC is responsible for providing outreach, disease management/case management, care coordination, education/training and motivational support to patients, referral sources and the community to encourage quality outcomes, smooth transitions and coordination of care across the health continuum, encourage healthy lifestyle choices and reduce long term effects of chronic illness. This position is accountable for working with and representing our clinic across multiple constituents.

ESSENTIAL FUNCTIONS

• Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community.
• Assess and identify participant’s readiness, willingness and ability to change, identify their coaching, support and educational needs, determine and provide relevant community and/or health care resources to support solutions; provide educational tools to promote self-management.
• Develops interventions and sets goals for behavioral modification within the scope of nursing practice.
• Conducts health and wellness coaching sessions to assist participants in making lasting changes to their health and wellness.
• Monitor and document the patient’s progress toward his or her optimal level of wellness.
• Promotes wellness and provides education regarding preventative care measures.
• Acts as a liaison between referral sources, facilities and outside entities to prevent and/or resolve continuum of care issues
• Communicates, as needed, with service delivery partners, providers and other health professionals to provide care coordination so as to ensure the plan of care facilitates the efficient use of health care resources.
• Demonstrates skills in effectively coordinating and monitoring care to promote quality and cost effective outcomes.
• Proactively follows up with patients discharged from all hospitals, rehab facilities and emergency rooms to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment.
• Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for tracking and care coordination purposes.
• Remains current on industry trends, best practice operational models, and changing patient and provider needs.
• Additional duties as assigned.

Requirements:

EDUCATION & TRAINING REQUIREMENTS

• NM RN License
• BSN Preferred
• BLS (American Heart Association)

WORK EXPERIENCE REQUIREMENTS

• 3 years clinical experience preferred
• Previous work experience with educating patients and patient goal setting preferred

Note: Job description available upon request.**All required documents must be presented at time of hire.**EXTERNAL APPLICANT: Employment is contingent upon successful completion of pre-employment drug and alcohol testing.GRMC is an Equal Opportunity Employer