Job Description -

• Care Planning and Self-Management Support
• Works with patient, PCP and other care providers to identify and prioritize patient's health care goals and develop a comprehensive care plan to achieve them.
• Assess patient knowledge of disease, self-management skills, and readiness to change and administers standardized health risk screening and assessments tools.
• Identifies and monitors measurable outcomes and clinical paraments appropriate for diagnosis, staging of medical conditions, progress towards care plan goals, and early identification of need to referral for urgent/emergent complications.
• Determines and conducts appropriate level of services and follow-up, including using care pathways or protocols to deliver time-limited, goal oriented clinical interventions.
• Provides health education, counseling, coaching and other therapeutic modalities (as appropriate) that may include group classes, one2one encounters and /or telephonic contact to help patient achieve self-management goals.

Requirements -

• A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State
• Valid and current certification in Basic Life Support (BLS) is available through the American Heart Association (AHA).