Graduate of an accredited nursing program, bachelor’s degree preferred; Current unrestricted RN state license; CCM or other similar certification preferred.
3-5 years acute care or community nursing
Proven history in coaching and facilitation. Strong ability to communicate verbally and in writing. Must be self motivated and be able to build and maintain relationships. Intermediate knowledge of Microsoft office and ability to navigate software system.
Knowledgeable of available community resources.
Minimal physical restrictions. Frequent manual dexterity with close mental/visual attention.
Ability to work with confidential information. Occasional travel required.
- Directs the patient’s care throughout the health care continuum
- Assesses, plans, implements, coordinates, monitors and evaluates an individualized plan of care for the patient that encompasses the medical, behavioral, and psychosocial realms of care.
- Responsible for the completion of a holistic assessment of patients including areas such as medical health, emotional well being, financial well being, housing, caregiver assistance, and care transitions from one health care setting to another.
- Ability to successfully transition a patient from one level of care to the other
- Ability to critically think and anticipate a patient’s needs.
- Working with the patient and their family to create a comprehensive, individualized plan of care to meet all health related goals.
- Ability to provide health education to patients and their families when indicated
- Coordinate the establishment of a medical home
- Coordinate any community resource referrals
- Communicate and coordinate with all members of the health care team
- Timely and effective engagement of potential Care Coordination recipients
- Ability to provide behavior modification and motivational interviewing techniques to elicit positive behavior change.
- Provide courteous and prompt service to all internal and external customers. Prioritizes and addresses requests and assignments in a professional manner to develop cooperative relationships and to ensure customer confidentiality at all times.
- Identifies opportunities and recommends methods to improve service, work processes and financial performance, e.g. program cost savings and other quality improvement initiatives.
- Assists in the implementation of quality improvement initiatives.
- Actively supports teamwork throughout the company.
- Performs other needed services as required.