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Chronic Care Navigator KEY AREAS OF RESPONSIBILITY:Develop a keen understanding of primary care practice requirements for optimal, coordinated population healthWork as an effective team member of the care teamCollaborate with care teams to establish population-appropriate, pre-visit, and point of care processesWork with the Phamily Chronic Care Management platform to support patients with multiple chronic diseases and assists in coordination of the patients care continuum.
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Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
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The position of the Nurse Chronic Care Coordinator, Remote will perform telephonic encounters with patients on behalf of our partners each month and develops detailed care plans within our care plan templates in the electronic health record.
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This entails executing tasks such as Transitional Care Management and Chronic Care Management to ensure comprehensive and effective healthcare support. These duties will include Transitional Care Management, Chronic Care Management of the HCMG patients.
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The Nurse Care Manager works closely with HarmonyCares Medical Group (HCMG) in home health care continuum and specialty services to maximize the health of the HCMG patients. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home.
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Phamily is a Chronic Care Management & Proactive Care Platform and More information about the program can be found here The Chronic Care Navigator is a medical assistant who supports the development of patient-centered, team-based care.
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Perform chronic care management for patients with conditions such as hypertension, diabetes, and asthma. Proficient in providing comprehensive primary care, including chronic care management, annual wellness visits for adults and pediatrics, and preventive health measures.
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Primary Care Nurse Practitioner or Physician Assistant. Strong understanding of Patient-Centered Medical Home (PCMH) principles and value-based care. Participate in quality improvement initiatives and value-based care programs.
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Phamily is helping to place a Chronic Care Manager/Chronic Care Navigator for our client in Austin, Texas. By gathering and organizing patient data, the Chronic Care Navigator works to identify patients’ unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team.
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Candidates will be considered who have experience and a strong interest in the prevention and management of chronic diseases, including cancer; cardiovascular disease; diabetes and obesity; chronic diseases and/or genetic epidemiology; health services research; patient and provider outcomes; quality of care and clinical effectiveness; racial disparities; and womens health.
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Care is provided throughout the entire continuum of care - from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care.
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The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients.
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Experience: 2 years experience within the last 5 years in chronic disease management/long-term care. As a hospice and palliative care nurse practitioner at Agape Care, you’ll provide patients with diagnosis, treatment, and care under the supervision of a physician.
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FNP (Family NP): (birth to death) Stable chronic disease state management, primary care across the lifespan. AGPNP/ANP (Adult Gerontology Primary Care NP or Adult NP): Adult pts (13 years to death), stable chronic disease state management or primary care setting.
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2+ years of related experience as a nurse practitioner, preferably with home-based visits, geriatrics, chronic disease management, and hospice and/or palliative care. Engage with Primary Care Physicians and other health care professionals in a collaborative relationship aimed at disease prevention, health promotion, and chronic disease management.
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