The Primary Care Nurse Coordinator performs Medicare Annual Wellness Visits to support wellness planning and management of chronic disease. Also provides education visits including diabetic education and other chronic disease education for populations identified through wellness visits, patient registries or by the clinic provider.

Actively outreaches to clinic patient’s post-hospital discharge for Transitions of Care coordination. 

• Assesses the healthcare, educational and psychosocial needs of the patient/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/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/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/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Facilitates/coordinates laboratory and diagnostic tests for all disease management 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 CPSL goals and strategic business strategies.
• Collects and prepares laboratory specimens (blood, urine, sputum, wound secretions) and completes associated paperwork (request slips, lab log, container labels, billing documents) 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/skin testing, under the direction of a provider and per scope of practice.
• Performs other duties as required or assigned.