Summary:

Supports the Nurse Care Management department in caring for rising-risk and high-risk patients and plays a key role in obtaining information about patients with medical and social needs.

Responsibilities:

Screens patient census using provided criteria to determine if the patient should be categorized as high risk Manages the high-risk patient census to assess if intervention from the Nurse Care Manager (NCM) or other disease management/population health program is needed Assesses patients for basic needs and intervenes when appropriate referring patients with greater needs to the NCM for intervention Works closely with the NCM to help patients reach their goals maintain safety and improve their health Has awareness and understanding of community and Coastal resources/teams to offer patients Hands off communication to the NCM or other Coastal program when necessary Works with the NCM to develop and update patient care plans and attends care conferences and huddles as needed Performs telephonic and remote patient outreach to patients documenting all outreach and interventions in the electronic medical record (EMR) Facilitates and reinforces patient self-management under the direction of the NCM and encourages patients to keep up to date with labs PCP and specialist visits and their care plan Evaluates for patient safety Ensures documentation is collected from patient specialist visits Provides resources and disease management education to patients Comfortable with MOLST and durable power of attorney forms to lightly discuss with patients Understands durable medical equipment (DME) needs and referrals Has in-depth understanding of medical insurances and benefits Assists patients with transportation needs Performs other job-related duties as assigned

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Lifespan is a VEVRAA Federal Contractor.

Location: CM-Wakefield-Wakefield Primary Care-59 South County Commons USA:RI:Wakefield

Work Type: Full Time

Shift: Shift 1

Union: Non-Union