Team Nurse

Job description

Job Summary This role works with a dedicated Primary Care Provider and supports primary care activities for the PCP panel, including patient education, orders, referrals, and medication management, and addressing gaps in care. The Team Nurse works directly with members to achieve their care plan goals through patient education, care coordination, and building relationship. Duties and Responsibilities: - Act as the practice-based nurse, supporting on-site providers in facilitating high quality primary care that promotes appropriate healthcare utilization. - Facilitate Patient Centered Medical Home (PCMH) functions through management of diagnostic order tracking, medication refills, review of the medical record, and fielding messages from members and the integrated care team. - Lead panel management for members attributed to the assigned primary care provider through activities including, but not limited to, following disease care pathways, entering standing orders for preventive care, and leveraging available reports to close care gaps. - Monitor access to the primary care provider. Ensure members have scheduled follow-up. - Coordinate services to complete primary care provider acti...