Lead and help drive the implementation of Populations Health/ACO initiatives at the community level with input from medical and operational leaders, as well as other key Steering Committee members. Coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family-centered.
Current licensure as a Registered Nurse required. Experience: Previous experience in caring for chronic disease patients required. 3-5 year experience in clinical or community health settings preferred. Previous Care Coordination, Case Management or Home Health experience preferred. Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills. Proficient in communication technologies (email, cell phone, etc.). Effective organizational skills and demonstrates ability to maintain accurate notes and records. Previous experience with health IT systems and data reports preferred. Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred. Ability to speak a relevant second language preferred. Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.