Assist the patient-centered medical home inter-disciplinary team and patient with development of care plans, coordination of services and addressing social determinants/barriers to care. Follow-up with high-risk patient populations, including care transitions and those patients with multiple chronic conditions, to review care plans and goals, updating as outcomes are achieved or additional goals or barriers are identified. Works with the patients and families to access resources and adopt healthy lifestyles.
Qualifications:
Degree or Diploma as Registered Nurse or Licensed Practical Nurse from an accredited School of Nursing. Licensed by the State of Arizona as an RN or LPN. Care Management certification preferred. Minimum eighteen (18) months to two (2) years related care management experience in a primary care ambulatory setting or equivalent nursing setting. Bilingual in English and Spanish. Must have the ability to interact with physicians and other healthcare professionals in a professional manner. Must have knowledge of physical and behavioral health medications and available community, local and regional social and/or health service agencies.