POSITION SUMMARY :

Responsible for follow up communication and coordination for continuum of care. Responsible for addressing any barriers and will communicate with department directors and physicians as required.

POSITION EDUCATION/QUALIFICATIONS :

• License Vocational Nurse (L.V.N.)
• Current Texas licensure
• Minimum of two year of clinical or related hospital experience
• Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians
• Demonstrated leadership experience
• Ability to read, write and speak English required
Ability to speak Spanish preferred

JOB KNOWLEDGE/ EXPERIENCE :

Representative challenges of this position include having a high degree of competency/experience in general. Requires good communication and organizational skills. Must Requires reasoning ability and good independent judgment. Must project a professional image. Working knowledge of personal computer and software applications used in job.

POSITION RESPONSIBILITIES :

• Responsible for phone-based interaction with patients after discharge
• Inform patients of abnormal laboratory results
• Educate patient and/or caregiver on disease specific education
• Coordinate follow up care with Primary Care Physician or Specialist as necessary
• Identify barriers to compliance with plan of care
• Refer to Care Link Clinic when needed
• Coordinate access to clinical and community based resources as appropriate
• Respond to triggers that may indicate intervention is required
• Assists with monitoring and continually assess the success of problem resolution activities.
• Completes and maintains records for problem status for follow-up.
• Maintains and distributes corrective action reminder report to responsible persons.
• Assist with meetings and disseminates information to appropriate areas, as directed.
• Able to travel and make home visits as needed.
• All other duties as assigned.