Purpose of Job: Improve the overall health of the communities we serve by managing patient care at assigned clinic as follows: Essential Duties and Responsibilities: Performs independent visits while operating under standing order procedures. Partners with provider on chronic care management and complex patient management. Performs medical flip visits with provider for hospital discharges, ER follow-ups, and other complicated visits. Facilitates general day-to-day flow of the clinic in close collaboration with other team members. Serves as liaison between outside providers/health care entities and the clinic. Collaborates with appropriate teams to design and test workflows and RN integration into the care team. Performs patient, family, and caregiver education including motivational interviewing and patient centered health action plans. Assists in improving the performance of identified quality measures and population health initiatives. Triages patients in clinic and over the phone as requested. For staff assigned to a specialty support role: Responsible for case management related to specific patient populations to ensure utilization of specialized healthcare services. Conducts regular assessment of patient needs and develops comprehensive plan of care. Collaborates with patient and Care Team for wrap around services. Conduct home health visits as determined in the care plan. Performs other duties assigned, including supporting the CHAS Health Mission and Core Values.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree