Pcmh Chronic Care Management Rn

Essential Functions:
Collaborate with providers in identifying patients with chronic disease and are appropriate for care management utilizing established standard care management criteria.
Performs initial and periodic holistic assessments for chronically ill patients Devises and implements a care management plan based on assessment findings Provide consultation and support to community regarding identified health issues / concerns.
Conduct medication reconciliations for patients who have discharges from the hospital and or / after office appointments Review monthly reports and communicate findings Seek culturally competent services to address the unique needs of each patient Skills Abilities: Ability to communicate clearly and effectively with co-workers and patients Ability to complete competency CPR and First Aid Ability to prioritize and compete multiple tasks simultaneously.
Effective oral and written communication skills.
Working Conditions: Possible exposure to inside environmental conditions.
Exposure to distressed patients, families, or visitors.
Physical Demands: Requires standing, sitting or walking for up to 8 hours or longer per day.
The ability to lift up to 50 lbs.
Requirements: Active Missouri RN license Experience and knowledge of EMR required.
BLS