ESSENTIAL DUTIES AND RESPONSIBILITIES:

·Adhere to the scope of practice per Colorado regulatory guidelines. Promote the level of clinical expertise required to provide safe, high quality outpatient case management nursing.

·Assists all patients through the healthcare system by acting as a patient advocate and navigator.

·Coordinates continuity of patient care with external healthcare organizations and facilities, including the process of hospital admission and discharge, and referrals from the primary care provider to a specialty care provider.

·Coordinates the continuity of patient care with patients and families following hospital admission, discharge, and ER visits.

·Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including registry.

· Supports patient self-management of disease and behavior modification interventions.

·Provide triage to patients navigating the health care system following nursing guidelines, protocols, and physician direction.

·Collect, prioritize, and synthesize comprehensive data pertinent to the patient health or situation to evaluate, classify, advise and disposition of the patient requests.

·Collaborate with patient, family, and others in the conduct of nursing practice.

·Incorporate factors related to safety, effectiveness, cost, and impact on practice in planning and delivering patient care in regards to resource utilization.

· Conducts comprehensive preventive screenings for patients and/or assists all support staff in daily patient interactions, as needed.

·Facilitates health and disease patient education, including leading group office visits/classes.

·Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

·Participates in Patient-Centered Medical Home team meetings and quality improvement initiatives.

·Facilitates patient medication management based upon standing orders and protocols.

·Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.

·Evaluates clinical care, utilization of resources, and development of new clinical tools, forms and procedures and works with the Patient-Centered Medical Home team (including Clinic Medical Director and Clinic Administrator) to implement these changes and updates.

EDUCATION and/or EXPERIENCE:

Bachelor’s Degree in Nursing with at least two (2) years of related experience in chronic disease management, case management and/or utilization management, pediatric experience preferred.

This position's hiring pay range is: $38.00 to $43.70 per hour, depending on education and experience.