Description Description 1. Knowledge in all aspects of the electronic medical record, including training and monitoring for compliance and timely follow-up 2. Responsible for the daily nurse visit schedule that includes billing and charting in a timely manner 3. Completes telephone and on site Triage, facilitating patient questions and answers for behavioral health and medical patients. Supports monitoring of patients awaiting behavioral health appointments as identified for follow-up by the PCP. 4. Coordinates care management for identified patient populations assigned to designated providers, including medical and behavioral health patients. 5. Provides case management for patients identified through the care team, developing coordinated plan of care to improve health outcomes of patient 6. Analyzes preventative screening data for designated patients, providing guidance to clinical support and providers for upcoming visits through onsite and electronic huddles. 7. Provides feedback to nurse manager regarding team member’s patient centered medical home activities 8. Participates in quality improvement, in-service workshops, continuing education and peer review as requested by management and supervision 9. Assist with and promote all processes associated with the Coleman initiative 10. Assist with and promote all processes associated with Patient Centered Medical Home standards 11. Any other duties and responsibilities as requested by management and supervision Requirements Requirements A. Graduate of an accredited RN nursing program B. Current New York State license in Registered Nursing C. Completes additional training for care management, SBIRT, Depression and Anxiety screening to support assessments for mental health and substance use disorder patients as applicable D. Demonstrate a willingness to accept direction from providers and Sr. VP/ CNQO E. Possess the ability to work well and with compassion in stressful situations F. Maintain a professional and courteous demeanor with both patients and co-workers G. Be keenly aware of the importance of confidentiality in all aspects of the position