Works with the providers and clinic staff to identify patients with Heart failure, IHD and ensures clinical guidelines are being followed

Triage patients, administer IV therapy under the direction of the providers, and relay test results after provider interpretation

Conducts Chronic Care Model visits and reviews the patient’s informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease

Utilizes appropriate motivational interviewing techniques necessary for coaching and assisting the patient to complete self-management goal / action plans

Enters timely and accurate data into the EMR system and other applications necessary to communicate patient needs and to ensure complete documentation of patient visits and phone calls

Responsible for remote monitoring of patients, setting parameters with provider direction, identify changes in patient vitals, conduct on - going discussions in regards to disease management with the providers

Maintains current knowledge regarding HF, IHD as well as treatments and medications related to each

Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians

Conducts clinic one-on-one visits with patients, triaging, educated on disease, diet, assess patient needs.  Communicates these needs to the appropriate person (i.e. Social Worker, clinic staff, etc.) or addresses them per process

Solves problems by gathering and / or reviewing facts and selecting the best solution from identified alternatives.  Decision making is usually based on prior practice or policy, with some interpretation.  Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures

Serves as a resource or consultant for LVN / MA team members

Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms

Collaborates with the cardiology team to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as HF, IHD, and all Cardiology related diseases

Exhibits professionalism and is courteous with all patients, physicians and co-workers

Performs all other related duties as assigned