Primarily responsible to promote the overall health and welfare of identified patients by fostering collaboration at the office level and across the health system. Serves as the patient’s advocate to assess, manage and monitor their individualized primary and social needs. Builds and maintains strong relationships with the patients, families and caregivers to develop and update personalized health goals to engage and empower patients and improve health outcomes.
Role Responsibilities: Provides care coordination to patients. Understands and appropriately identifies and manages patient populations with unmet primary or social needs, high risk for readmission and uncontrolled chronic conditions utilizing EMR, registries and reporting. Coordinates continuity of patient care and transitional care management services with patients and families following hospital admissions, discharge and ED visits. Conducts comprehensive and preventive screenings for patients. Completes outreach to patients that: have gaps in care and initiates action designed to close those gaps; that have not been seen within 30 months, those that are eligible for an Annual Wellness Visit. Plans, facilities and provides health coaching and disease patient education across all patient populations to encourage patients to become proactive in their plan of care. Ensures applicable patients of the practice receive annual physical exam and/or annual health risk assessment including completion of required documentation by payer contract if indicated. Evaluates and refers patients to Population Health, as appropriate, when acuity indicates and/or as defined in the policy and procedure. When appropriate and/or when referred, facilitates discussion with patient and family members on advanced care planning directives and services. Helps develop KPIs and identify workflow and operational opportunities for better patient care. Integrates into the clinic and is seen as one of the care team members and a go-to resource. Participates in the Patient-Centered Medical Home Transformation, including attending team meetings and any quality/continuous improvement transformation initiatives as needed. Promotes and continuously exhibits World Class Teamwork and communication among all members of the care team and across the health system.
Must have ASN from accredited program. BSN preferred.
Must have valid Indiana Registered Nursing License. Must have current BLS certification.
Minimum of 3 years in ambulatory care or hospital setting preferred.