Primary Responsibilities:
Chronic Care Management
Working with patients through telephone communication to achieve health goals set by their providers.
Reviewing care plans with patients via telephone communication.
Chart reviews and reconciliation.
Assist patients with management of chronic diseases through telephone interactions.
Assisting with community resources and assistance as needed.
Facilitate routine appointment booking and provide reminders.
Coach patient/families toward successful self-management of their chronic disease.
Use tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
Promote health behaviors in all populations and ensure navigation assistance with community resources.
Assess the patient’s medical, functional, and psychosocial needs, perform medication reconciliation with review of adherence and the patient’s medication self-management.
Assist patients with management of chronic diseases through telephone interactions.
Transitional Care Management
Contacting patients post hospital discharge to review discharge instructions, ensure patient understands medications and coordinate post hospital follow-up appointments.
Assist patient’s with transition management between and among health care providers and settings, including referrals to other clinicians, and assisting with making follow-up appointments after a visit to the emergency department after discharges from hospitals, skilled nursing facilities, or other health care facilities. Facilitate communication of relevant patient information through electronic exchange of a summary care records with other healthcare providers regarding these transitions.
Minimum Requirements:
Current licensure as a Licensed Practical Nurse required.
Proficient telephone skills required.
Demonstrates the ability to create and manage a patient-centered plan of care including care for chronic conditions.
Demonstrates evidence of essential leadership, communication, education, and collaboration skills.
Proficient in communication technologies (email, phone, EMR, etc.)
Typing proficiency of at least 30 wpm.
Effective organization skills and demonstrates ability to maintain accurate notes and records.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.