Primary Responsibilities and Specific Duties:
- Consistently participates in and actively adheres to patient care expectations to attain clinical goals set forth by supervisor.
- Continue to act as an advocate for individual care needs by identifying and communicating opportunities for care interventions, including identifying and addressing functional deficits and gaps in care.
- Follow up with patient hospitalizations, emergency or urgent visits, institutional facility admissions and re-admissions to identify issues and implement follow up to improve patient outcomes.
- Establishes and maintains professional working relations with referral sources, community resources and care providers.
- Routinely assesses the progress of patient follow up with the monitoring of patient?s status, needs and progress; if progress is static or regressive, and proactively encourage appropriate adjustments to their plan of care, provider and /or services to promote better outcomes
- Participates in data collection and research activities related to the delivery of services and patient level outcomes.
- Participates in team meetings to communicate and address patient care and operational requirements.
- Develops and implements targeted strategies to improve care coordination for patients with chronic diseases such as diabetes, hypertension and asthma in accordance with established clinic policies and procedures, objectives, quality improvement activities, safety, environmental and infection control standards.
- Ensures that tracking and follow up are performed on client care visits at CHC and treatment received at other medical centers, including but not limited to stat and urgent orders and referrals; medical care services such as preventive care screenings and assessments and abnormal laboratory results for specific tests in a timely manner.
- Informs supervisor of any management or operating problems that may affect quality and the standards of patient services.
- May be required to travel to other CHC locations as assigned.
- Performs other duties as assigned.
- High school diploma or equivalent required; completion of an Accredited Licensed Practical Nurse or Registered Nurse Program; Active Florida LPN or RN license.
- Minimum of two (2) years' experience as a LPN or RN in Health Care or Managed Care is preferred.
- Proven ability to function effectively as a member of an interdisciplinary team and proven experience in verbal and written communications and case management service skills.
- Knowledge of health implication of chronic diseases and risks.
- Excellent skills in oral and written communications skills.
- High level of initiative and leadership.
- Good advocacy skills.
- Must have proven ability in handling multiple projects and setting priorities, as well as effective time management.
- Bilingual: English/Spanish helpful.
- Able to work flexible hours and other CHC locations as needed.