Job Summary This role supports care management activities and value-based care initiatives for ambulatory services, specifically within the medical group. Performs all duties as assigned. Job Responsibilities • Collaborate and participate in Baptist Medical Group’s care management and value-based care initiatives. • Provide education to patients and caregivers regarding self-management of health care conditions that are appropriate based on language, cognitive abilities, literacy levels, patient preferences, and readiness for change. • Facilitate the transition of patient care from inpatient settings such as hospitals, rehabilitation facilities, and skilled nursing facilities back to the patient’s home or community setting. • Develop a comprehensive, collaborative care plan, based on the provider’s treatment plan. • Assist patients with care coordination needs, including provider referrals, medication refills, appointments, and preventive screenings, as appropriate. • Promote patient adherence to provider recommendations and treatment plan. • Collaborate with providers to strengthen clinical documentation and support risk adjustment initiatives. Minimum Required Experience 3 years of nursing experience on current unit or in specialty area. Preferred/Desired Experience Experience with care coordination, case management, or utilization review processes. Minimum Required Education BSN or equivalent years of nursing experience Minimum Required Special Skills Strong analytical and data management skills. Comfortable seeking direction and assistance from appropriate resources. Ability to communicate effectively verbally and in writing. Proficient ability to use a computer and electronic medical record. Comply with all HIPAA regulations to maintain patient, team member and employer confidentiality. Customer service oriented, friendly, cheerful, helpful and cognizant of patient needs. Ability to work independently and exercise clinical judgment in interactions with providers, payers, patients, and their families. Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components. Preferred/Desired Special Skills Familiar with scope of practice and licensure regulations. Minimum Required Licensure RN BLS certification within 14 days of hire