About the Role
The nurse in this role will lead patient care coordination, delivering education, monitoring health status, and supporting treatment adherence for individuals with chronic conditions in an outpatient environment.
Responsibilities
- Conduct initial and ongoing patient assessments to determine care needs
- Develop individualized care plans in collaboration with healthcare providers
- Educate patients and families about disease management and treatment options
- Monitor patient progress and adjust care strategies as needed
- Coordinate transitions of care between settings
- Ensure compliance with clinical protocols and documentation standards
- Serve as a clinical resource for patients between appointments
- Facilitate communication among care team members
- Promote patient engagement in self-management practices
- Track clinical outcomes and report on performance metrics
- Support quality improvement initiatives
- Participate in interdisciplinary team meetings
- Maintain current knowledge of clinical guidelines
- Assist with patient onboarding and orientation
- Provide telehealth support when required
- Document patient interactions in the electronic health record
- Respond to patient inquiries in a timely manner
- Identify barriers to care and recommend solutions
- Collaborate with social workers and care coordinators
- Ensure continuity of care during hospitalizations or changes in status
- Support patient adherence to prescribed therapies
- Conduct home safety assessments when applicable
- Assist in care plan reviews with supervising clinicians
- Maintain patient confidentiality per regulatory standards
- Participate in professional development activities
Compensation
Competitive salary and benefits package offered
Work Arrangement
Full-time, on-site position
Team
Part of a multidisciplinary care team focused on patient-centered outcomes
About the REACH Program
The REACH program focuses on proactive, holistic care for patients with chronic conditions, emphasizing early intervention, education, and coordinated support to improve long-term outcomes and reduce hospitalizations.
Why Join Us?
This role offers the opportunity to make a meaningful impact on patient lives through personalized care, supported by a collaborative team and structured clinical framework.
Not available for this position
