RN, Chronic Disease Case Manager

1. Wellness Prevention & Quality Collaborate with members of the health care team to assist patients with wellness to include wellness exams and healthy living habits. Review registry information for assisting to meet the needs of patients and provide quality of care. Review Quality measures and assist providers and the primary care team to meet and exceed metric benchmarks. Educate patients regarding wellness and prevention to achieve quality of life. Review value-based contract metrics to assist the primary care team to implement workflows assisting patients to achieve quality goals. 2. Care transitions/ Patient navigation Follow patients through the health care system assisting with transitions with primary care, specialists, and ancillary departments to ensure their understanding of treatment. Introduce patients to available programs –TCM (transitional care management), CCM(chronic care management), PCM (principal care management) and RPM (remote patient monitoring) to assist in self-management of chronic disease and co-morbidities Collaborate with the primary care team, patients, caregivers, and family to ensure patients’ needs are met at the point of care. Assist patient with SDoH (social determinants of health) needs and allocating resources. Lead the primary care team to achieve health equity for all patients seen in primary care. 3. Health coaching/goal setting & care planning Communicate and collaborate effectively with health team members. Educates patients regarding chronic disease & comorbidities, assists with self-management. Identify and recognize abnormal symptoms/changes in patient condition. Appropriately, reports condition changes to medical provider. Encourages adoption of habits that are conducive to a higher quality of life. Utilizes Motivational Interviewing to assist patients in reaching their health care goals. Collaborates with patients to develop patient centered plans. 4. Performs other duties as assigned.