RN-Chronic Care Management

Canyonlands Community Health Care•Page, AZ

2d•$73,600 - $103,020•Onsite

About The Position

This position assumes advocacy and accountability for an identified group of patients during all or part of the continuum of care. Focuses on primary disease prevention and improving quality of care for chronically ill patients and outreach to patients to be more engaged in their overall health and wellness through care planning and management. Collaborates with the health care team members to identify appropriate utilization of resources.

Requirements

Basic Function: This position assumes advocacy and accountability for an identified group of patients during all or part of the continuum of care.
Focuses on primary disease prevention and improving quality of care for chronically ill patients and outreach to patients to be more engaged in their overall health and wellness through care planning and management.
Collaborates with the health care team members to identify appropriate utilization of resources.
Successful completion of a background check and drug screen are a prerequisite to employment.

Responsibilities

Collaborates with health care staff responsible for patient care to develop, implement, monitor and evaluate appropriate clinical care or other services to meet the needs of patient and coordinates all activities related to chronic care management.
Plans for, ensures access to, and evaluates the effectiveness of care at the next level of care along the continuum of care.
Ensures that areas of responsibility are operating in compliance, including documentation and records with all federal, state, and regulatory agencies.
With the primary care team, identifies patients to be case managed, assesses patient’s care requirements, modifies or coordinates modification of patient care and intervenes, as necessary.
Coordinates in the development and review of clinical pathway trends and shares with appropriate service and management teams.
Assist with monitoring of quality improvement elements including establishment of program measures and implementation of action plans.
Works directly with the Population Health Director and Community Health Workers to establish and implement outreach tasks and patient centered engagement.
Monitors trends and implements strategies to assist patient with accessing appropriate level of care.