• Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient and readmission visits.
• Functions as a clinical liaison, facilitator, advocate and collaborator in a multidisciplinary care team across the continuum of care to provide complex disease management interventions to high risk and post discharged patients identified.
• Utilizing assessment skills and risk assessment tools to collect subjective and objective information pertaining to the health status of the patient and identify barriers that will require a team-based approach.
• Utilize a team-based, holistic, patient-centered, evidence-based approach to identify patient-centered goals and develop outcomes to improve the health status of Emory Healthcare patients and improve patient satisfaction.
• Conducts targeted outreach to identified patient panels to ensure timely and efficient care delivery across the continuum of care. Improve communication and collaboration between patient and families, healthcare teams and community-based organizations. Performs patient re-assessments to determine current health status and progress toward healthcare goals and care plan completion.
• Conduct systematic, ongoing, and criterion-based evaluation of outcomes in care coordination plans of care.
• Updates patient care plan, as appropriate. Ensure care gaps are closed around specialty/chronic diseases. Serve as a primary point of contact for identified high risk and post-discharged patients and facilitate access to services.
• Enhance health literacy by using teach back and other various forms of learning validation. Provide self-management support with the use of information technologies to communicate health promotion and disease prevention information.
• Partners with other care coordination teams across the Emory Healthcare system and community organizations. Assimilate and document the results of the evaluative processes. Apply critical-thinking skills and the use of clinical judgement when implementing population health interventions or planning effective care for groups or individual patients and their families.
• Facilitates transformational care delivery in clinical settings and advance the mission and goals of population management activities.
• Monitor key measures of performance, quality improvement and care transformation in the assigned clinical area.
• Integrate data analysis and performance improvement initiatives into practice with the aim of improving care coordination among multiple entities. Participates in professional organizations and attend continuing education activities to maintain knowledge of current trends and practices as it relates to care coordination and population health. In addition, other area specific job duties.
  
  MINIMUM QUALIFICATIONS:
• Graduate of an accredited nursing school. Bachelors degree in Nursing (BSN) required.
• Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
• Care Management experience preferred.
Three (3) years of healthcare experience required. BLS Healthcare Provider certifications required.

PHYSICAL REQUIREMENTS: