Full time
Key Responsibilities:
Identify patients requiring preventive care, chronic disease management, laboratory tests, screenings, or referrals, and coordinate services to meet their needs. INRs, stress tests, BP checks, remote device checks, and additional responsibilities assigned by the manager.
Perform transitional care management, including reviewing hospital discharge information, conducting medication reconciliation within two days of discharge, and scheduling follow-up appointments.
Triage patient phone calls and respond to inquiries with clinical expertise, ensuring timely and accurate resolutions.
Communicate test results to patients under provider supervision, offering appropriate guidance and next steps.
Support medication adherence through patient education and follow-up communication.
Accurately and efficiently document medical information in the electronic medical record system, maintaining compliance with documentation standards.
Lead efforts to close preventive care gaps and monitor clinical quality measures, ensuring the practice meets all associated metrics.
Promote best practices and contribute to the practice's success in achieving quality and operational goals.
Qualifications:
Active Pennsylvania RN license
Strong communication, organizational, and critical-thinking skills.
Skills and Attributes:
Proficient in care coordination and transitional care management.
Demonstrated leadership in quality improvement initiatives and closing care gaps.
Ability to manage multiple tasks efficiently in a dynamic environment.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 123,000 colleagues and nearly 27,000 physicians and clinicians caring for diverse communities across 26 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 135 continuing care locations, the second largest PACE program in the country, 136 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $21.5 billion with $1.4 billion returned to its communities in the form of charity care and other community benefit programs.
