RN, Clinical Care, Prim Care - The University of Rochester : Job Details

Integrates and coordinates access and utilization management, proactive patient management, care facilitation, and treatment planning functions. Coordinates the medical care of high-risk patients identified through health risk assessment/appraisal or physician clinical determination. Provides targeted outreach and follow-up, assisting in care plan development for medically complex patients, and identifying barriers to successful care management. - - ESSENTIAL FUNCTIONS - - Coordinates medical care of patients identified as high risk through clinical determination or health risk assessments. Assumes a coordination role at the point of service and through targeted outreach and follow-up. Identifies patient groups with chronic diseases and assists in developing and implementing population-based strategies to close gaps in medical care. Identifies resources for patient self-management skills. Assists in developing and implementing care plans for medically complex patients, ensuring alignme...Clinical, Clinic, Management, Health, Healthcare, Medical, Patient