Patient Management Nurse

JOB SUMMARY:

• Requires the application of a variety of procedures, policies, and/or precedents relating to both the standards and procedures of the nursing profession and those established by Aegis Medical Group
• Provides advice and follow-up education consistent with patient's age and cultural needs.
• Responds to patient inquires, prioritizing responses, and routing urgent situations to a physician, APRN, or PA (hereafter provider).
• Maintains accurate and appropriate documentation and follows patient privacy in accordance with HIPAA and Aegis Medical Group policies and procedures.
• Performs to the level of a Registered or Licensed Practical Nurse as dictated by the Florida Nurse Practice Act.

JOB DUTIES:

• Identifying high-risk patients and establishing goal-driven educational touchpoints aimed at independent self-care and admission prevention.
• Providing transitional care to patients with recent admissions and/or ER visits.
• Referral management and optimization
• Working with health plans to connect patients with services that are offered
• Identifying and resolving health care barriers for patients
• Telephonic and in-person interaction with patients
• Participation in patient education events
• Connecting patients with community resources
• Developing rapport with patients and encouraging them to call you directly with any questions or concerns.
• Interaction with all patients that are new to the practice and hospital/ER follow ups.
• Assisting patients with acute medical needs by triaging them in office or via telephone, communicating with provider to obtain orders/treatment plan, and following up with patient to ensure plan is carried through.
• Assisting the providers in office with hands on patient care when needed
• Schedule patient appointments as needed
• Communication with providers regarding clinical opportunities such as, avoidable admissions, readmissions, high-cost medications, etc.
• Review and understanding of provider scorecards and performance from a patient management perspective, identify areas of opportunity, and develop action plan for improvement.