Transitions of Care RN 100% Virtual, CareBridge
Core
Conduct behavioral and clinical assessments to identify patient needs, coordinate health coaching plans, and facilitate referrals for chronic disease management in home and community settings.
Role type
Licensed Nurse (Transitions of Care RN)
Builds
Health coaching plans and care coordination for members with chronic diseases
Domain
Healthcare / Chronic Disease Management
Deliverable
client delivery
Required skills
Behavioral or clinical assessments, health coaching, motivational interviewing, care plan coordination, provider network navigation, case management
Preferred skills
Spanish fluency, home health experience, catastrophic case management 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 to address objectives and goals; Interfaces with provider and other health professionals to coordinate health coaching plan; Implements and/or coordinates coaching and/or care plans by educating members regarding clinical needs and facilitating referrals; Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed; Directs members to facilities, community agencies and appropriate provider/network; Refers member to catastrophic case management