Care Coordination, RN - Full Time

Essential Functions And Responsibilities

• Interact with patients telephonically (audio and video) for care coordination.
• This may include, but is not limited to: Medicare Wellness Visits, Transitional Care Management, Chronic Care Management, Medication Reconciliation, documentation of patient reported home vitals, and outreach that supports coding efforts and the closure of quality gaps.
• Absorb and assist patients in gaining access to PCP and specialist appointments as needed within recommended time frames following provider protocols and scheduling best practices.
• Participate as an active member of the patient’s care team collaborating with the patient, patient’s family, providers, clinical staff, and outside care entities.
• Develop and implement goal-driven, individualized patient care plans. These care plans will include a focus on disease management and patient empowerment.
• Educate patients’ families and care-givers in the execution of these care plans.
• Monitor care plans to review patient’s progress and revise as necessary while continuing to provide education and support as appropriate.
• Document all encounters and patient related discussions. Close documentation in a timely manner.
• Properly utilize technology in support of patient care.

Requirements

• Registered Nurse license for the State of Florida and two years’ experience working in both inpatient and ambulatory care setting (physician office setting, hospital or Hospice).
• Proficiency with Excel is preferred.
• Excellent listening and interpersonal skills.
• Ability to maintain confidences.
• Must be flexible, resourceful, and able to problem solve.
• Must be able to handle multiple tasks simultaneously and set Priorities.