Nurse Disease Management I (US)
Core
Conduct behavioral and clinical assessments to identify patient needs, coordinate health coaching plans, and facilitate referrals for chronic disease management.
Role type
Licensed Nurse Disease Management Specialist
Builds
Health improvement and management programs for members with chronic diseases
Domain
Healthcare / Chronic Disease Management
Deliverable
client delivery
Required skills
Behavioral assessment, clinical assessment, health coaching, motivational interviewing, care plan coordination, provider network navigation, case management
Preferred skills
Case management experience, OB/Maternity/Labor and Delivery experience, Pediatrics experience
Technologies
None stated
Responsibilities
Conduct behavioral or clinical assessments to identify individual member knowledge, skills and behavioral needs; Identify and/or coordinate specific health coaching plan needs; Interface with provider and other health professionals to coordinate health coaching plan; Implement and/or coordinate coaching and/or care plans by educating members regarding clinical needs; Use motivational interviewing to facilitate health behavior change; Monitor and evaluate effectiveness of interventions and/or health coaching plans; Direct members to facilities, community agencies and appropriate provider/network; Refer member to catastrophic case management