Community Health Nurse

Interested in joining one of the fastest growing companies in Healthcare that is redefining our communities? This may be the position for you.
Manage a case load of 100 patients - they become your patient panel
Develop trust and build rapport with a selected patient population
Establish "call me first" relationship with these patients- patients are encouraged to call your cell phone including after hours
Engage patients telephonically, in office, in facility, or where needed
Act as the liaison between the PCP and patient
Assist patients in accessing care at the appropriate source
Have attention to detail for patients: medical, social, family, economical, and behavioral issue- work to mitigate these barriers
Develop relationships with the care coordination teams
Lead case rounds, huddles, and PCMH Care Coordination for your patient panel
Understand and utilize the Athena Clarity and Applications to determine high value opportunities
Review patient non-compliance issues and conduct outreach to close them
Maintain a courteous and helpful manner when working with patients, physicians, and associates
Schedule your paneled patients for diagnostic testing and follow up to ensure completion of testing
Work in collaboration with nurse educator and Clinical Operations Specialists to achieve Targets for Quality Improvement
Participate in special projects and perform other duties as assigned
Effectively communicates with staff and patients
Demonstrate sound judgment
Maintain a positive caring attitude towards patients
Strong computer and EMR skills and expertise
Must be detail oriented and possess varied analytical skills
Possess a focused work ethic and a high level of professionalism
Flexible, as work location is field based
Self-motivated and therefore identifies opportunities and finds solutions
Able to multitask effectively
BS in Nursing (or equivalent) and at least 3 years of case management or care coordination experience.
Active unrestricted license in VA, DC, MD or able to obtain (if needed)

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