Acts as a clinical resource, change agent, research mentor, and consultant to assist in planning, implementing, and coordinating patient care for selected patients across the continuum.

Prioritizes patients for case management by identifying high risk patients, frequent admissions, re-admissions within thirty days, and progressive chronic illness.

Collaborates with patients/families and health care providers to achieve optima l patient outcomes, make change or recommendations to plan of care.

Synthesize data including patient outcome data to make clinical decisions to influence care practices and policies.

Serves as a consultant to unit staff regarding resource utilization, care planning, and evidence-based practice.

Provides disease management education to patients and families. Assist with developing and updating educational materials.

Performs other duties as assigned.

MINIMUM

DESIRABLE

Education, Credentials, Licenses:

Master’s degree in nursing. Graduate of an accredited school of Nursing. Licensed to practice nursing in the state where work is being performed. Meets contact hour requirements for licensure, including all state required courses. CPR certified.

Certified Nurse Leader (CNL)

Specialized Knowledge:

Extensive knowledge of best practices and clinical guidelines, Chronic Disease Management. Ability to educate, engage and motivate patients to improve overall wellness and outcomes.

Certification in Chronic Disease Management, HF, Population Health Management

Kind and Length of Experience:

Proven leadership ability, advanced critical thinking and interpersonal communication and skills. Minimum three to five years of experience as RN in acute primary care setting. Demonstrates ability to work autonomously and can provide direction to nurses, physicians, and ancillary staff concerning best practices.

Previous experience as a Clinical Outcomes Manager and an accomplished negotiator.