Community Registered Nurse-Medicine

Job description

Under supervision of the Nurse Manager and/or clinical Nurse Practitioner (NP), the Nurse Care Coordinator will work in collaboration and continuous partnership with the high risk and/or high utilizer patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, as well as full care coordination team to: promote timely access to appropriate care, reduce emergency room utilization and hospital readmissions, improve quality metrics, create and promote adherence to care plans, and increase patients’ ability for self-management and shared decision making. This role is patient focused, outcome-oriented, and based on general and specialty professional standards, and functions within the multidisciplinary practice model. ESSENTIAL FUNCTIONS: - Receives referrals from clinic staff and assists with the identification of high risk/high utilizer patients using available electronic resources and databases (CRISP) and maintains a patient registry. - Works on or with a multi-disciplinary team including social work, pharmacy, diabetes educator, nurses and in collaboration with the patient, primary care provider and family/caregivers to create care plans for patients inclu...