Chronic Care Navigator - Goa, India - Phamily

Description

LPN Chronic Care Manager – TeleConnected Medicine

2855 Old Highway 5, North Blue Ridge, GA 30513

TeleConnected Medicine is actively recruiting a licensed nurse to join our Chronic Care
Management Team. This team member will serve our patients by utilizing best-in-class
operational and clinical models. You will be making a life changing impact on our rural Medicare
participants by delivering patient centric, team and community -based care management models
that support patients wherever they are. At TeleConnected Medicine, we combine
compassionate attention and excellent communication between our patients and providers to
address the full continuum of our patient's health care and social determinant needs. Join us in
this exciting opportunity as we grow and expand to change lives within rural communities

Role Description:
Implements and coordinates all case management activities relating to catastrophic cases and
chronically ill patients across the continuum of care including consultant referrals, community
resources, and alternative levels of care. Interacts with patients using state of the art digital
technology and streamlined patient communication tools.

Responsibilities and Activities:

• Care plan development using AI and Digital tools to develop a plan of care under direct supervisor of Primary Care Provider.
• Facilitate the patient's appropriate condition management and optimize wellness and medical outcomes.
• Seamless communication with patient's clinical care team for care management.
• Monitor patient progress toward desired outcomes through assessment and evaluation.
  

Required Qualifications [Background Experience Desired]

• Licensed Nurse or Associates degree with equivalent experience
• Minimum 3-5 years clinical practical experience preference: (Diabetes, CHF, CKD, Post-Acute Care, Hospice, Palliative Care, Cardiac) with Medicare participants.
• Minimum 2-3 years Care Management, discharge planning and/or rural health care coordination experience
• Excellent analytical and problem-solving skills
• Effective communications, organizational, and interpersonal skills
• Ability to work independently (may require working from home).
• Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.
• Efficient and Effective computer skills including navigating multiple systems and keyboarding