Location: all cities,AK, USA
Primary Responsibilities:Role embedded within the primary care clinic, working directly with patients, clinical and non-clinical teamsParticipates in the identification of a focused clinic patient panel, as defined by the manager of Medical ManagementSupports longitudinal care of the patient with chronic care conditions:Communicates with patients, responding to patient questions via patient portal and other modalitiesPerforms assessment of health conditions and implements care plan in collaboration with the member, caregiver(s), clinician(s), and/or other appropriate healthcare professionals to address need and goalsPursues appropriate interventions to reduce risk of condition exacerbation, ER and hospitalization utilizationPerforms medication reconciliation and collaborates with clinician partner as neededConducts Motivational Interviewing and Self-Management Goal settingProvides patient educationCreates referrals to appropriate agencies and resourcesSupports transition of care from Emergency Department or inpatient stay to outpatient setting:Performs assessment of transitional needsPerforms medication reconciliationEstablishes and reviews contingency planProvides patient educationAssists with post discharge needs such as home health care, prescriptions, transportation, Durable Medical Equipment (DME), appointmentsCoordinates with providers to establish or update individualized plan of careCreates referrals to appropriate internal and external resourcesAchieves Quality Measures outcomes via reduction in HEDIS Gaps in CarePerforms accurate and timely documentation in the electronic medical recordPerforms triage and clinical tasks within their scope of practiceParticipates in daily huddles and monthly clinic meetings, as requiredPrepares accurate and timely reports, as requiredMaintains continued competence in nursing practice and knowledge of current evidence-based practicesPerforms ongoing updates of the care plan to evaluate effectiveness, and to document interventions and goal achievementMaintains a working knowledge of community resourcesServes as facilitator and resource for other members of the Medical Group clinical teamAttends departmental meetings and provides constructive recommendations for process improvementPerforms other duties as assignedYou'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:Associate degree in nursingValid NM RN License or valid multi-state compact licenseCurrent BLS CertificationMust be 21 years or older and have a valid NM State Driver's license3+ years of previous job-related experience in a healthcare environmentKnowledge of medical terminologySkilled with MS Office software applicationsFull COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation