Major Responsibilities:

• Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient's status and determines priorities of patient care based on essential patient needs. Ensures necessary documentation is complete.
• Collaborates with the patient/family and inter-professional team in evaluating change readiness, assessing patient's wants and needs, developing plan of care, designing teaching plans/programs, promoting self-care skills, and evaluating the patient's progress toward goals and expected outcomes. Maintains a patient-centered, whole person approach to care.
• Serves as a clinical resource to others by establishing clinical expertise in management of assigned population and keeps up-to-date on current evidence.
• Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.
• Facilitates appropriate and prompt access to primary care providers, physician specialists and other services as needed. Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) to ensure smooth transitions of care.
• Provides patients and families appropriate community resources, as needed. Acts as a resource on care coordination and as a patient liaison to providers, clinical staff, other clinical services or facilities and the community.
• Collaborates with Care Management to identify applicable resources and previously identified best practices. Monitors patient registries to identify patients overdue for visits, labs, or referrals; arranges follow-up services as appropriate and updates health information records.
• Conducts current and retrospective clinical reviews for the purposes of determining best practice patient care outcomes including most cost effective, appropriate care for the patient, and the effectiveness of care coordination. Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes.
• Communicates and collaborates with the local and extended care team to ensure a smooth flow of information and teamwork. Delegates technical activities that do not require a Registered Nurse to perform to appropriate team members.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.
• Basic Life Support (BLS) for Healthcare Providerscertification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required.

Education Required:

• Bachelor's Degree in Nursing.

Experience Required:

• Typically requires 5 years of experience in clinical nursing that includes experience in nursing assessment, care plan development and in educating patients.

Knowledge, Skills & Abilities Required:

• Working knowledge of the components of quality and patient care needs specifically related to the area in which care will be performed.
• Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum.
• Excellent analytical and interpersonal communication skills necessary to negotiate with families, patient, physicians and third party payers.
• Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
• Critical thinking ability to prioritize in a busy practice with a lot going on at the same time
• Ability to work independently
• Triage experience is a plus

Physical Requirements and Working Conditions:

• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment.
• Operates all equipment necessary to perform the job.

Additional Schedule Information:

• Position splits time between multiple sites.
• One day a month at St. Luke's South Shore. Regular schedule with some variables; One day a week at St. Luke's, two days at 84South, other two days at Mayfair location.
• Each week will be a little different, Mayfair is the primary location.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.