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.