ESSENTIAL FUNCTIONS OF THE ROLE

Assesses plans, implements, documents, coordinates, monitors, evaluates and updates the plan of care by collaborating with all members of the health care team to provide evidenced based care.

Establishes patient care management plans, interventions, treatment goals and self-management goals.

Assesses the health care, educational and psychosocial needs of the patient and family.

Assists patients with self-management through education, visits and telephonic engagement; encourages and supports patient adherence to their care plans.

Researches, evaluates and recommends resources to meet medical and non-medical needs of patients and families. Collaborates, refers and communicates across all programs to ensure appropriate coordination of services.

Researches and takes an active role in identifying problems and possible solutions in the coordination of care to determine most appropriate setting.

Acts as liaison to hospital, long-term care, specialists and home health representatives.

KEY SUCCESS FACTORS

Associate's degree in nursing.

Specialty Certification strongly encouraged.

Knowledge of care management, resource and utilization management.

Skilled in care management and patient assessments.

Excellent verbal and written communication skills required.

Ability to monitor, assess and record patient progress against a plan of care.

Ability to facilitate patient access to community resources.

Ability to work collaboratively with both internal and external medical staff and external partners and organizations.

Ability to assess, adapt, and calmly respond to changing and crisis environment.

Ability to maintain confidentiality with all aspects of patient information in accordance with all applicable policies and regulations.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level