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Primary Responsibilities:
Conduct comprehensive assessments of high-risk members to evaluate clinical, functional, and psychosocial needs.
Develop and implement individualized, goal-oriented care plans in collaboration with primary care providers and the interdisciplinary care team.
Continuously monitor, evaluate, and adjust care plans to ensure appropriate, cost-effective levels of care and optimal patient outcomes.
Identify and coordinate non-medical support services (e.g., housing, transportation, and community resources) to enhance compliance with treatment plans.
Facilitate seamless transitions of care by collaborating with physicians, social workers, discharge planners, and claims professionals.
Utilize specialty resources and clinical expertise to achieve optimal patient outcomes and minimize preventable complications.
Maintain detailed documentation of assessments, care coordination activities, and measurable outcomes in compliance with organizational and regulatory standards.
Promote health education, disease prevention, and early intervention strategies to improve overall member well-being.
Serve as a patient advocate by ensuring privacy, confidentiality, and respect throughout all phases of the care process.
Qualifications:
Associate’s or Bachelor’s degree in Nursing or a related healthcare field (BSN preferred).
Current, unrestricted state Registered Nurse (RN) license.
Strong analytical and clinical judgment skills with the ability to interpret complex medical data.
Proven ability to work collaboratively across multidisciplinary teams and manage multiple priorities effectively.