Collaborate with providers in identifying patients with chronic disease and are appropriate for care management utilizing established standard care management criteria.
Performs initial and periodic holistic assessments for chronically ill patients
Devises and implements a care management plan based on assessment findings
Provide consultation and support to community regarding identified health issues / concerns.
Conduct medication reconciliations for patients who have discharges from the hospital and or / after office appointments
Review monthly reports and communicate findings
Seek culturally competent services to address the unique needs of each patient
Skills Abilities
Ability to communicate clearly and effectively with co-workers and patients
Ability to complete competency CPR and First Aid
Ability to prioritize and compete multiple tasks simultaneously.
Effective oral and written communication skills.
Working Conditions
Possible exposure to inside environmental conditions.
Exposure to distressed patients, families, or visitors.
Physical Demands
Requires standing, sitting or walking for up to 8 hours or longer per day.