Job Description

Job Responsibilities:

• Demonstrates expertise in navigating electronic medical record and other care management applications.
• Collaborates with team members in the discharge process, performing outreach/documentation according to CMS guidelines and the Population Health workflow.
• Outreach to TOC patients should focus on medication reconciliation/adherence, self-management, use of personal health records, follow-up with PCPs/Specialists, and review of indicators that a patient’s condition is worsening and how to respond.

Skills:

• 3-5 years of clinical experience required.
• 2 years of Home health experience preferred.
• 2-3 years of managed care and/or care management experience preferred.

Education/Experience:

• Bachelor’s Degree in Nursing.
• Registrations, or Certifications: RN license in the state of employment or compact is required.

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