Description:

• [Population Health
• Responsibilities:

• • Responsibilities include, but are not limited to, comprehensive patient assessment, symptom management, data analysis, care planning, case management, implementation of interventions, and evaluation of outcomes for patients with past, current, or suspected chronic diagnoses.
  • Chronic Conditions management, focused on outreach and management of the disease state (renal, respiratory as example), disease management specifically in diabetes, respiratory, or renal care.
  • Develop and facilitate individualized plans of care in collaboration with treating physicians, patients, their support networks, and family members. Coordinate and modify plans of care as needed to ensure seamless, patient-centered care across inpatient, outpatient, home, and other supportive care settings.
  • Perform clinical assessments and triage of new and established patients (including patients enrolled in clinical research studies) by telephone, in clinic, or in collaboration with the interdisciplinary healthcare team. Coordinate appointments for specialty consults, procedures, diagnostic testing, and support services within established service lines.
  • Deliver ongoing patient and caregiver education related to diagnoses, treatment plans, medications, symptom management, self-injection techniques, specialty-specific devices, and disease self-management. Monitor treatment response, identify side effects or dose-limiting toxicities, communicate findings to treating providers, and implement timely interventions.
  • Maintain collaborative relationships with physicians, primary care providers, specialty services, diagnostics, laboratory, radiology, inpatient teams, and other key stakeholders to ensure coordinated care, continuity of services, and optimal patient outcomes.
  • Support clinical quality and professional practice by identifying quality indicators, conducting systematic reviews, maintaining specialty-specific databases, reviewing policies, implementing evidence-based practice improvements, and ensuring compliance with clinical standards, protocols, and quality requirements.
• Float department (if needed): Supporting different specialties- renal, respiratory, and diabetes all in the same location
• Certificates required:RN License, CPR