Job Summary:

Primarily responsible to promote the overall health and welfare of identified patients by fostering collaboration at the office level and across the health system. Serves as the patient’s advocate to assess, manage and monitor their individualized primary and social needs along with assessing the health status of patients using Remote Patient Monitoring (RPM) Technologies. Builds and maintains strong relationships with the patients, families and caregivers to develop and update personalized health goals to engage and empower patients and improve health outcomes.

Role Responsibilities:

• Provides care coordination to patients.
• Understands and appropriately identifies and manages patient populations with unmet primary or social needs, high risk for readmission and uncontrolled chronic conditions utilizing EMR, registries and reporting.
• Coordinates continuity of patient care and transitional care management services with patients and families following hospital admissions, discharge and ED visits.
• Monitors patients vital signs, symptoms, and medication adherence using RPM technologies.
• Provides timely interventions based on assessment findings.
• Participates in ongoing training to enhance RPM skills.
• Conducts comprehensive and preventive screenings for patients.
• Completes outreach to patients that have gaps in.

QUALIFICATIONS

Education:

Must have ASN from accredited program. BSN preferred.

License & Cert:

Must have valid Indiana Registered Nursing License. Must have current BLS certification.

Experience:

Minimum of 3 years in ambulatory care or hospital setting preferred.