LPN / Registered Nurse

• Implements a multidisciplinary treatment education and adherence program focused on high risk patients that includes one-on-one teaching.

Including: - Supervises Care Coordination for Chronic Disease Management

- Monitors work flow to Care Coordination team as appropriate

- Works with Medical Providers and Data Staff to improve Quality

• Develops care plan and other case management tools by: meeting with patients; coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; fostering peer support; and providing education to others regarding the case management process.
• Monitors delivery of care by: meeting with patients; documenting care; identifying progress toward desired care outcomes; intervening to overcome deviations in the expected plan of care; reviewing the care plan with patients in conjunction with the care team.
• Evaluates outcomes of care with the interdisciplinary team by measuring intervention effectiveness with the team; implementing team recommendations.
• Provides triage and advice services (electronic, phone and telemedicine).
• Assists with prescription refills, pharmacy communications and medication reconciliation
• Assembles information concerning patient's clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to specialist.
• Contacts review organizations and insurance companies to ensure prior approval requirements are met. Presents necessary medical information such as history, diagnosis and prognosis.
• Reviews details and expectations about the referral with patients.
• Assists patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
• Provides written educational materials as needed to inform clients about treatment regimens, particularly the need for compliance with medications prescribed.
• Provides support to Medical Assistants.
• Tasks as assigned

Job Type: Full-time

Required Experience and Qualifications:

• Strong interest in public health/ chronic disease management
• Charge Nurse Experience or Management experience preferred
• Team Player

Education Requirement:

Bachelor’s of Science in Nursing

Required license or certification:

Registered Nurse (RN)