This position supports Arlington, Gaylord, Henderson, Winthrop and Belle Plaine and Le Sueur Clinics.

Purpose of Job

This position is responsible for serving as a patient advocate to assist rising risk and high risk/complex chronic patients in reaching optimal function and health.

Job Functions

• Manages disease registries to identify gaps in care.
• Assess and analyzes patient information for proactive identification and planning of appropriate services to meet the needs of the patient and family.
• Integrates recommendations by multiple professionals and service systems to coordinate care across the continuum and assure appropriate utilization of clinical and community resources.
• Develop and deliver comprehensive care plans in partnership with patients/families and care team to enhance the patient's care and achieve patient health goals.
• Promote patient wellness and self-management skills.
• Assist patients and their families in navigating between multiple care providers and transitions across all healthcare settings.
• Provide continual evaluation of patient outcomes and identification of variances in standards of care and system problems that could lead to errors, delays in care, complications or increased costs.
• Performs other duties as assigned.

Minimum Education/Work Experience

• Graduate of an accredited school of nursing
• 5 years of clinical nursing/ambulatory care experience

Knowledge/Skills/Abilities

• Knowledge of basic computer functions and Microsoft Office applications
• Ability to meet and maintain the necessary background checks as aligned with position functions
• Capable of making independent decisions with the use of good critical thinking and problem solving skills
• Ability to respond appropriately to unpredictable situations and diverse patient populations
• Ability to demonstrate exceptional communication and customer service skills
• Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above

License/Certification

Current professional nurse licensure in Minnesota or if licensed in another state, a permit from the Minnesota Board of Nursing while the license application is in process
Current Healthcare Provider CPR certification

Preferred Qualifications

• Previous RN Care Coordination, Care Management, Care Navigation and/or Care Transitions experience
• Previous experience in a Health Care Home environment
• Working knowledge of motivational interviewing, behavioral activation and shared decision making
• Experience with the diversity of the local community

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