Under the supervision of the Diseases Management Supervisor, performs work as Health Center’s disease case manager at the point of service of patients as well as other networks of communication as needed.
Assume a leadership role in the multidisciplinary care team in order to insure high quality patient care and appropriate allocation of services and resources.
Serve as a liaison and educator, and coordinate health care resources on a continued basis such as referral to Nutritionist and/or other Specialty Providers.
Assist with identifying opportunities for and facilitating alternative care options based on patient needs and assessments.
Collaborate with the Addabbo Health Care Team including the Clinical Nutritionist and Health Educator to coordinate and implement educational seminars on pertinent chronic disease, nutrition and self-management goal to children/parents or guardians, adolescents and adults.
Educate Health Center patients (from all Departments) on an individual basis on health and disease education. This includes clinic attendance to other Health Center sites (Sites 2 and 3) as assigned by the Diseases Management Supervisor and approved by the Executive and Medical Directors.
Encourage and support patient/family in setting self-management goal, documentation of patient goal and follow up with patient.
Perform follow up re-assessment or evaluation of patient’s health knowledge and progress in patient self-management goal via phone call and encourage patient to keep follow up appointment.
Perform case and disease management of patient like adherence to prescribed medications and other treatment plan, keeping follow up appointment, referral to other Specialty Provider and pertinent laboratory and diagnostic tests.
Delegate and support Health Educator when conducting outreach sessions in nearby area’s, hospitals and clinics, performing home visits and scheduling patient follow up clinic visit.
Supportive role to the Clinical Nutritionist.
Under the supervision of the Diseases Management Supervisor, participate in the implementation of the special health projects of the Health Center related to chronic diseases management (use of IT disease/case management tools).
Generate periodic reports related to process and outcomes measures of special health projects as directed by the Disease Management Supervisor and/or Executive and Medical Directors.
Maintain open lines of communication with an emphasis on supportive relationship.
Develop linkages with Health Education Programs to improve quality of patient information and referral systems.
Keep abreast of health information and utilize current data in education of patients.
Attend State and Local meetings and conferences as prescribed by the Executive and Medical Directors.
Attend Addabbo Management Meetings and other related In-service meetings.
Handle confidential information.
**This job’s specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.
Bachelors of Science in Nursing with (MASTERS DEGREE preferred)
Registered Nurse Licensure
Knowledgeable of the concepts and philosophy of Case Management
Minimum two year experience in chronic disease case management (Hospital, Skilled Nursing Facility or Clinic)
Familiar with current relevant medical standards of practice and Evidence Based Medicine
Strong leadership, communication and computer skills