Transitions of Care RN 100% Virtual, CareBridge
Core
Conducts behavioral and clinical assessments to identify patient needs, coordinates health coaching plans, and facilitates referrals for chronic disease management in home and community settings.
Role type
Licensed Registered Nurse (Transitions of Care)
Builds
Health coaching plans and care coordination for members with chronic diseases
Domain
Healthcare / Chronic Disease Management
Deliverable
client delivery
Required skills
Clinical assessment, health coaching, motivational interviewing, care plan coordination, referral management, disease management
Preferred skills
Spanish fluency, home health experience, case management experience, compact RN license
Technologies
None stated
Responsibilities
Conduct behavioral or clinical assessments, coordinate specific health coaching plans, interface with providers to coordinate care, implement coaching plans, monitor intervention effectiveness, direct members to community agencies, refer to catastrophic case management
Seniority
Individual Contributor