Location: Baltimore, MD
room utilization and hospital readmissions, improve quality metrics, create and promote adherence to care plans, and increase patients' ability for self-management and shared decision making.
This role is patient focused, outcome-oriented, and based on general and specialty professional standards, and functions within the multidisciplinary practice model.
ESSENTIAL FUNCTIONS Assists with the identification of high risk/high utilizer patients using available electronic resources and databases and maintains a patient registry. Works a multidisciplinary team including social work, shop, diabetes educator, nurses and in collaboration with the patient, primary care provider and family/caregivers
to create care plans for patients including high-risk, high utilizer patients, patients with multiple co-morbidities and/or at high risk for readmission to a hospital setting.
Works with patients both in person and on the phone to monitor adherence to care plans, evaluate effectiveness, monitor patient progress, and facilitate change as needed. Assists patients through the healthcare system by acting as a patient advocate and navigator and promoting timely access to appropriate care. Promotes clear communication between care teams and treating clinicians by ensuring awareness regarding patient care plans and being mindful of cultural and language preferences of patients. EDUCATION and/or
EXPERIENCE Bachelor's Degree, or diploma in Nursing from an Accredited institution Current Maryland licensure or eligibility to obtain Maryland licensure.
Excellent customer service and communication skills Two to three years clinical experience. For more details: jobs-search. org/legal_baltimore-c434177/nurse-care-coordinator-psychiatry-baltimore_i1959977689
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