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Serves in an expanded nursing role as part of an interdisciplinary team to promote preventative patient care, offer screening services, and coordinate disease management services while also providing primary clinical support to the provider, patient and their family to assist in the diagnosis and treatment of the patient's condition. Assists clinic team with triage of in basket messaging as needed and management of patient interaction with the clinic identifying patient needs, intervention pathways, clinical guidelines and diagnostic tests to develop individualized plans of care.
The Primary Care Nurse Coordinator performs Medicare Annual Wellness Visits to support wellness planning and management of chronic disease. Also provides education visits including diabetic education and other chronic disease education for populations identified through wellness visits, patient registries or by the clinic provider.
Actively outreaches to clinic patient's post-hospital discharge for Transitions of Care coordination.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
We're proud to offer competitive salaries and a comprehensive benefits package that includes:
For more information, please call 1-888-491-8833 Ext. 1896 (Extension Required) or e-mail firstname.lastname@example.org
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