Identifies opportunities in the medical home and manages and coordinates clinical care of defined populations with identified preventive care and/or chronic disease needs in the outpatient setting. Functions as a resource to patients and families and actively role models patient and family centered care. Contributes to the development and maintenance of a patient/family centered care delivery system and promotes effective resource utilization. Responsibilities: Follows-up on assigned complex patients, Post Hospital Discharge, to assess status and determine next step. Manages and coordinates clinical care of high risk and complex ACO populations in the outpatient setting. Performs outreach, needs assessments, validates medication and assess gaps in care in order to develop individualized care plans in alignment with patient goals and expectations. Barriers to care are assessed and connections to local resources are made as required. Provides face to face encounters for complex patients and serves as the point of contact for high risk patients and families. Facilitates education opportunities and risk avoidance, assists in establishing effective patient provider interaction, ensures patient understanding of the treatment plan and works with the patient to develop goals and strategies. Assesses registry and other reports to extract appropriate high risk and complex cases. Provides disease education to patients and families using interactive tools such as Emmi. Performs Annual Wellness Visits and Advanced Care Planning for complex patients. Participates in case conferences with care teams as well as in All Staff Current Daily Huddles. Coordinates the hand off of patients to team nurses when stable and continues to mentor and support team nurses in care coordination tasks. Participates in applicable Quality Improvement projects as assigned. Performs other duties as required or assigned. Minimum Qualifications: Bachelor’s degree or equivalent with 3 years of clinical experience required. Excellent assessment, communication, interpersonal, and organizational/time management skills. Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment. Excellent verbal and written communication skills. Sound decision making, judgment, time management and negotiating skills. Familiarity with electronic medical records, and computer applications including MS Word and Excel. Must demonstrate passion for care of patients with chronic disease. Sound decision making, judgment, and negotiating skills. Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors. Required Licensure/Certification Skills: Basic Life Support (BLS) Certificate required upon hire and as applicable, higher level per unit certification requirements as stated on the grid attached to the AHA and Life Support Policy. RN in the state of NHTracking

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