- Provide patient-centered coordination of care management to medically complex, high-risk patients who have been discharged from an acute or sub-acute inpatient facility.
- Perform telephonic patient assessment with information obtained from discharge summary and patient/caregiver to establish patient health status, identify early health issues and potential barriers of the discharge plan of care.
- Complete discharge medication reconciliation, identify discrepancies or adherence barriers and accurately document the encounter in the medical record.
- Review discharge summary instructions and provide care coordination, follow up lab and diagnostic studies, specialty and primary care provider appointments.
- Provide health coaching and education to patient/caregiver on discharge summary plan of care.
- Encourage self-engagement with a focus on achievement of goals and identifies barriers to adherence.
- Document summary of the patient/caregiver encounter in patient's EHR according to BIDHC protocols.
- Identifies clinical issues and lapses in standards of care and notifies appropriate provider and staff.
- Collaborates with provider or other practice team members to ensure all aspects of patient's plan of care has been met.
Requirements
- Graduate from an accredited Nursing Program required.
- Bachelor's degree in Nursing preferred.
- License Registered Nurse preferred.
- American Heart Association – Basic Life Support Certificate required.
- Licensed Practical Nurse (LPN) 3-5 years related work experience required.
- Detail oriented with the ability to work in a fast paced, high call volume team environment.
- Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications.
- May produce complex documents, perform analysis and maintain databases.
- Advanced understanding of computer skills - email, typing, accessing work systems.
Core Competencies
Demonstrates expertise in patient-centered care coordination for high-risk patients, including telephonic assessments, medication reconciliation, and health coaching. Proficient in documenting encounters in EHR systems and collaborating with healthcare teams to ensure comprehensive care delivery.
Highest-signal resume keywords
- Patient-Centered Care Coordination
- Telephonic Patient Assessment
- Medication Reconciliation
- EHR Documentation
- Health Coaching
ATS Optimization Keywords
Hard Skills
- Patient Assessment
- Medication Reconciliation
- Care Coordination
- Clinical Issue Identification
- Health Education
Soft Skills
- Detail Oriented
- Team Collaboration
- Self-Engagement Encouragement
Certifications & Qualifications
- Registered Nurse License
- Basic Life Support Certificate
Industry Keywords
- Patient Care Management
- Discharge Planning
- High-Risk Patient Care
- Caregiver Education
- Healthcare Collaboration
Tools & Technologies
- Microsoft Outlook
- Microsoft Word
- Microsoft Excel
- Microsoft PowerPoint
- Web-Based Applications