• ​Assesses the healthcare, educational and psychosocial needs of the patient and family and involves them in establishing a treatment plan based on realistic goals and interventions.
• Investigates healthcare options and facilitates communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment.
• Applies age-appropriate learning principles to educate patients, family and other health care members on the role and purpose of Care Coordination, its processes, disease, and case management programs and outcomes.
• Serves as a resource to patients, families and other healthcare team members regarding disease management.
• Implements clinical interventions based on risk stratification and evidence-based clinical guidelines.
• Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating and adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.
• Coordinates laboratory and diagnostic tests for all disease management programs. Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating and adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.
• Facilitates and coordinates laboratory and diagnostic tests for all diseasemanagement programs.
• Maintains required documentation in EPIC for all disease management activities.
• Collects and enters data and patient information according to department standards.
• Attends and participates in professional and nursing continuing education programs and exploits professional development opportunities.
• Reviews the current literature regarding effective teaching/learning strategies and disease management strategies and incorporates the appropriate techniques into disease management practice.
• Maintains active involvement in post-discharge Transitions of Care coordination.
• Assists leadership in the design, implementation and evaluation of care coordination programs to support overall goals and strategic business strategies.
• Collects and prepares laboratory specimens and completes associated paperwork to expedite laboratory studies with maximum accuracy and efficiency.
• Inserts, monitors, regulates and discontinues IV's as required by provider and per scope of practice.
• Administers medications and vaccines, including intradermal and skin testing, under the direction of a provider and per scope of practice.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.