Summary:

Coordinates team-based care to provide health services to individuals, families and/or their communities through effective partnerships with patients, their caregivers and their physician Provides prescribed medical treatment and personal care services to ill, injured, convalescent, and disabled persons in clinic setting by performing the following duties. Essential Duties and Responsibilities include the following. Other duties may be assigned. Coordinates services with a primary focus on improving the patient experience, increasing quality of care and reducing healthcare spending. Acknowledges patients rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations. Demonstrates continual learning skills, affects changes in approach to care based on established evidence based practice. Provides a coordinated strategic approach to detect early and manage effectively the patient with chronic disease. Establishes an effective internal tracking system for identified patients. Coaches patients/families toward successful self-management of their chronic disease. Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator). Ensures effective tracking of test results, medication management, and adherence to follow-up appointments. Understands and demonstrates proper safety procedures when working with Negative Pressure Therapy, layered compression wraps, removing staples/sutures, handling gas cylinders, and measuring and numbering wounds Understands and demonstrates proficiency when conducting a Semmes-Weinstein monofilament exam, transcutaneous oxygen monitoring exam, when using a smoke hood and operating the Hyperbaric Chamber. Interprets physician's orders and secures a requisition before performing test. Education and/or Experience 3 5 years experience in clinical or community health settings. Previous Care Coordination and/or Case Management experience preferred. Certificates, Licenses, Registrations Graduate of an accredited school of nursing preferred. CPR certification preferred Education and/or Experience 3 - 5 years experience in clinical or community health settings. Previous Care Coordination and/or Case Management experience preferred. Certificates, Licenses, Registrations Graduate of an accredited school of nursing preferred. CPR certification preferred