Description Summary/Objective Responsible for actively participating in the management of patients with complex needs to include conducting telephonic visits for Medicare Wellness, Transitional Care Management and Chronic Care Management. This role requires the ability to develop care plans and assist in the management of “high utilizers”. and identifying barriers in care to assist with successfully managing the patient’s disease state. He or she will work with care teams and patients to support the goals of providing efficient, effective, and quality care to our community. Essential Functions and Responsibilities • Interact with patients telephonically (audio and video) for care coordination. This may include, but is not limited to: Medicare Wellness Visits, Transitional Care Management, Chronic Care Management, Medication Reconciliation, documentation of patient reported home vitals, and outreach that supports coding efforts and the closure of quality gaps. • Assist patients in gaining access to PCP and specialist appointments as needed within recommended time frames following provider protocols and scheduling best practices. Participate as an active member of the patient’s care team collaborating with the patient, patient’s family, providers, clinical staff, and outside care entities. • Develop and implement goal-driven, individualized patient care plans. These care plans will include a focus on disease management and patient empowerment. Educate patients’ families and care-givers in the execution of these care plans. Monitor care plans to review patient’s progress and revise as necessary while continuing to provide education and support as appropriate. • Document all encounters and patient related discussions. Close documentation in a timely manner. Appropriately bill for services rendered. • Properly utilize technology in support of patient care. Basic knowledge of Microsoft Office Suite. Utilize Epic Healthy Planet suite of products for the support of care coordination. Supervisory Responsibility This position has no supervisory responsibility Work Environment & Physical Demands Possesses the physical stamina, cognitive functions and emotional stability essential to meet the demands of a fast-paced, highly productive and often highly stressful work environment Manual dexterity required: As needed for general administrative work, keyboarding, etc. Travel Local hospitals for rounding on patients and meetings along with Skilled Nursing Facilities. Requirements Required Education and Experience Registered Nurse license for the State of Florida and two years’ experience working in both inpatient and ambulatory care setting (physician office setting, hospital or Hospice). Proficiency with Excel is preferred Excellent listening and interpersonal skills Ability to maintain confidences Must be flexible, resourceful, and able to problem solve Must be able to handle multiple tasks simultaneously and set Priorities Preferred Education and Experience Bachelor’s degree, Case Management Certification Experience in a Primary Care Setting