Responsibilities
- Perform thorough clinical, psychosocial, and functional evaluations to determine patient needs, risks, and objectives.
- Create, execute, and sustain individualized, evidence-based care plans in partnership with patients, families, primary care providers, and interdisciplinary teams.
- Deliver nursing interventions and clinical support consistent with established care plan goals, protocols, and accreditation requirements.
- Track patient progress through regular follow-ups, data analysis, and reassessments; modify care plans as necessary.
- Establish condition-specific escalation protocols with providers for non-emergency acute changes.
- Coordinate care across multiple providers, care settings, and services to ensure seamless transitions and care continuity.
- Collaborate with patient navigators and non-clinical staff to address social determinants such as housing, food security, transportation, and community support.
- Act as a clinical advocate to help patients access services requiring nursing licensure or clinical oversight.
- Manage referrals and ensure timely follow-up to recommended treatments and resources.
- Foster trusting, empathetic relationships with patients and families using culturally sensitive communication.
- Educate patients on medical conditions, treatment options, self-care techniques, and healthcare system navigation.
- Support patients in making informed health decisions and achieving greater independence in managing their care.
- Ensure accurate, timely, and compliant documentation in electronic health records and care management platforms.
- Apply evidence-based clinical guidelines, internal protocols, and quality benchmarks such as NCQA and HEDIS.
- Engage in quality improvement, utilization review, and performance initiatives as required.
- Uphold patient confidentiality and comply with all regulatory, accreditation, and organizational policies.
Work Arrangement
Remote
