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Essential Job Duties/Responsibilities:
- Conduct in-home and telephonic visits to at-risk patients to prevent hospital admissions or readmissions.
- Coordinate initial assessment and care plan development for follow-up visits by LPNs.
- Supervise LPN visits and provide additional patient education as needed.
- Perform clinical and social determinants of health screenings in the outpatient setting.
- Coordinate and oversee the plan of care, ensuring patient needs are met and services are available in the community.
- Facilitate patient access to community resources and provide support for patient self-management.
- Maintain communication with families, community providers, and others to promote patient health and well-being.
- Utilize critical thinking and clinical skills to assess patients' progress and adjust care plans accordingly.
Knowledge, Skills and Abilities:
- Strong interpersonal and communication skills.
- Ability to work autonomously and exercise independent judgment.
- Proficiency in Microsoft Office Suite and other relevant software.
- Valid, active RN license and a minimum of 2 years' clinical work experience required.
- Certification through CCMC or CMCN desired.
Education and Experience Criteria:
- Associate degree in Nursing required
- Bachelor's degree in nursing or related clinical field preferred
- Valid driver's license required
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