Chronic Care Lead Nurse Job Avenue Healthcare
Medical Jobs. Avenue Healthcare Jobs.
Job Objective/Purpose
The Chronic Care Lead Nurse performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care nurse works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision- making.
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Key Responsibilities
- Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner.
- Responsible for registry of chronic care management (CCM) to patients.
- Validates enrollment of CCM patients based on provider request
- Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR.
- Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.
- Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.
- Facilitates patient access to appropriate medical and specialty providers.
- Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates
- Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education
- Educates patient and family/caregiver(s) about relevant community resources.
- Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.
- Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
- Supports patient self-management of disease and behavior modification interventions.
- Provides patient health counseling, education and instruction.
- Any other duty assigned by your immediate supervisor in line with the job description.
Person Specification
- Graduate of an accredited nursing school as a Registered Nurse with a Diploma/Degree in Nursing, valid license with the Nursing Council of Kenya.
- Updated BLS, ACLS/ATLS certificate
- Minimum of 3 years’ work experience in a healthcare setting involving patients with complex chronic disease states preferred.
- Customer focus, empathetic and emotional intelligence
- Strong interpersonal and communication skills
- Organizational awareness and attention to detail
- Team work and result oriented
- Ethical and reliable
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How to Apply
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