This position supports Arlington, Gaylord, Henderson, Winthrop and Belle Plaine and Le Sueur Clinics.

Purpose of Job

This position is responsible for serving as a patient advocate to assist rising risk and high risk/complex chronic patients in reaching optimal function and health.

Job Functions

1. Manages disease registries to identify gaps in care.
2. Assessand analyzes patient information for proactive identification and planning of appropriate services to meet the needs of the patient and family.
3. Integrates recommendations by multiple professionals and service systems to coordinate care across the continuum and assure appropriate utilization of clinical and community resources.
4. Develop and deliver comprehensive care plans in partnership with patients/families and care team to enhance the patient's care and achieve patient health goals.
5. Promote patient wellness and self-management skills.
6. Assist patients and their families in navigating between multiple care providers and transitions across all healthcare settings.
7. Provide continual evaluation of patient outcomes and identification of variances in standards of care and system problems that could lead to errors, delays in care, complications or increased costs.
8. Performs other duties as assigned.

Minimum Education/Work Experience

• Graduate of an accredited school of nursing
• 5 + years of clinical nursing/ambulatory care experience

Knowledge/Skills/Abilities

• Knowledge of basic computer functions and Microsoft Office applications
• Ability to meet and maintain the necessary background checks as aligned with position functions
• Capable of making independent decisions with the use of good critical thinking and problem solving skills
• Ability to respond appropriately to unpredictable situations and diverse patient populations
• Ability to demonstrate exceptional communication and customer service skills
• Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above

License/Certification

• Current professional nurse licensure in Minnesota or if licensed in another state, a permit from the Minnesota Board of Nursing while the license application is in process
• Current Healthcare Provider CPR certification

Preferred Qualifications

• Previous RN Care Coordination, Care Management, Care Navigation and/or Care Transitions experience
• Previous experience in a Health Care Home environment
• Working knowledge of motivational interviewing, behavioral activation and shared decision making
• Experience with the diversity of the local community

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