Status/Schedule: Full Time
For more information contact: Leslie Bradshaw, firstname.lastname@example.org
- Education: Licensed by the Kentucky Board of Nursing as a RN or LPN
- Experience: Preferred 2 years
- Additonal: BLS or be willing to obtain within 12 months of hire
- Enroll, monitor, and educate patients in our Chronic Care Management program.
- Provide continuing care after hospital discharge for Medicare patients through our Transitional Care Management program
- Perform and schedule annual wellness visits under the guidance and supervision of our medical providers.
- Set performance goals with ACO Coordinator to strive for Outstanding Care Here each month.
- Participate in daily huddles with Wellness Team. Identify scheduling opportunities, determine special needs for patients arriving at that office/clinic day, identify patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts.
- Ensure review of patient record to identify gaps in problem list prior to provider visit, post reminders to secure that all comorbidities are discussed and documented during AWV.
- Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
- Establish counseling services or providing resources to assist with obesity, tobacco cessation, diabetes prevention/management, depression, anxiety and managing cardiovascular disease as directed by the provider.
- Our ultimate goal is to help patients succeed and reduce hospital admissions for Medicare patients
- Can pay attention to detail and accuracy of documentation of records.
- Has the ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities.
- Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, providing throughout patient education, and working with disparate populations preferred.
- Ability to identify and implement appropriate patient communication strategies.
- The demonstrated ability to work constructively with all disciplines related to caring for patients within the community.