Overview
Job Summary
This role supports care coordination activities within ambulatory services, specifically for the medical group. Performs all duties as assigned.
Job Responsibilities
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Collaborate in overseeing the practice's care coordination initiatives.
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Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
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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.
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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.
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Identifies and implement cost effective problem solving, process improvement, risk assessment and the reduction of waste.
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Completed assigned goals.
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Purpose of Position and Scope of Responsibility Principal Accountabilities/Responsibilities Minimum Qualifications
Minimum Education
BSN or equivalent years experience
Minimum Experience
3 years’ experience on current unit or in Specialty area
Minimum Licensure, Registration, Certification
Desired Qualifications
Desired Education
Masters in Nursing or related field
Desired Experience
Exp with utilization review processes
Desired Licensure, Registration, Certification
Registered Nurse and CPR
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