Summary: Utilizing a team based model, provides health coaching to improve the overall health of the patients.
Responsibilities: include the following
Using motivational interviewing approach to encourage patients to set self-management goals to improve health status.
Assists the care team in reviewing tracking reports, patient outreach, and analysis of patient population best practice outcomes.
Supports Care Management of high risk patients.
Supports Patient Centered Medical Home (PCMH) model and clinic transformation process to implement PCMH concepts.
Initiates a patient education plan, including patient and family instruction, according to the individualized needs of the patient as prescribed by Physician
Collaborates with the patient as well as providers regarding opportunities for optimizing care
Evaluates patient understanding of the physician’s treatment plan, including but not limited to, prescriptions, refills, medical supplies, referrals, authorization of services, and when to seek care
Interviews patient and/ or family to further assess social, emotional, functional and physical health status
Provide patient education and instruction to promote self-care.
Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows all HIPAA guidelines and regulations
Participates in Quality Improvement (QI), Quality Assurance (QA) and Continuous Quality Improvement Activities (CQI) as appropriate.
Monitor the patient population HEDIS measures outcomes and coordinate patient care to impact a positive change to improve patient health status and chronic disease control.
Under the direction of the provider, executes standing orders to assure preventive, chronic, diagnostic and medication needs of the patient are met; facilitates the highest quality of care and efficient patient flow in a team based care environment.
Home visits for patient education and coordination of treatment plan.
Patient visits to coordinate care post hospital or ER visits to assist with treatment plan compliance.
Assist with nursing coverage in clinic setting.
Other duties as assigned by management
Education & Experience: Bachelors of nursing degree (RN) with minimum of three years practical experience, preferably in a primary care home health and outpatient setting. Experience in nurse case management or chronic disease management preferred. Working knowledge of PCMH also preferred.
Communication Skills: Able to effectively communicate with staff, physicians and patients. Customer services experience is preferred.
Computer Skills: To perform this job successfully, an individual should have knowledge of Microsoft Word and Excel software and experience working with electronic medical records.
Certificates and Licenses: Active RN license with State of Tennessee License. Maintain driver’s license. Will require travel between CHS sites.Apply Now