MAJOR RESPONSIBILITIES

• Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team.
• Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable

• · Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers.
• · Reviews patient medical record to identify care gaps.
• · Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter.
• · Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services.
• · Assists Nurse Navigators' in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines.
• · Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing.
• · Facilitates a collaborative approach with care team for identification of and closure of care gaps.
• · Utilizes educational and behavioral change strategies to promote patient collaboration with the care team.
• Incorporates excellent written, verbal and listening communication skills, positive relationship building skills and problem solving into patient care coordination practice.
• Performs duties as required or assigned for specific operational purposes for which they are qualified to perform.
• Maintains all professional CEU's in compliance with State and Regulatory requirements.
• Maintains confidentiality in all areas at all times.