Serves in an expanded nursing role as part of an interdisciplinary team to promote preventative patient care, offer screening services, and coordinate disease management services while also providing primary clinical support to the provider, patient and their family to assist in the diagnosis and treatment of the patient's condition. Assists clinic team with triage of inbasket messaging as needed and management of patient interaction with the clinic, identifying patient needs, intervention pathways, clinical guidelines and diagnostic tests to develop individualized plans of care. Assesses the healthcare, educational and psychosocial needs of the patient and family and involves them in establishing a treatment plan based on realistic goals and interventions. Investigates healthcare options and facilitates communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment. Applies age-appropriate learning principles to educate patients, family and other health care members on the role and purpose of Care Coordination, its processes, disease, and case management programs and outcomes. Serves as a resource to patients, families and other healthcare team members regarding disease management. Implements clinical interventions based on risk stratification and evidence-based clinical guidelines. Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating and adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Coordinates laboratory and diagnostic tests for all disease management programs. Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating and adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Facilitates and coordinates laboratory and diagnostic tests for all disease management programs. Maintains required documentation in EPIC for all disease management activities. Collects and enters data and patient information according to department standards. Attends and participates in professional and nursing continuing education programs and exploits professional development opportunities. Reviews the current literature regarding effective teaching/learning strategies and disease management strategies and incorporates the appropriate techniques into disease management practice. Maintains active involvement in post-discharge Transitions of Care coordination. Assists leadership in the design, implementation and evaluation of care coordination programs to support overall goals and strategic business strategies. Collects and prepares laboratory specimens and completes associated paperwork to expedite laboratory studies with maximum accuracy and efficiency. Inserts, monitors, regulates and discontinues IV's as required by provider and per scope of practice. Administers medications and vaccines, including intradermal and skin testing, under the direction of a provider and per scope of practice. Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

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