·         Work in collaboration with multidisciplinary provider team to provide innovative and evidence-based care

·         Actively manage all care coordination efforts, along with the CTA, for an assigned panel of high-risk patients to include but not limited to pre-visit preparation, referrals to specialists, hospitalizations and transitions of care, ancillary testing, acquisition of medical equipment and other enabling services

·         Anticipate the needs of the patient panel and collaborate with the CTA to ensure that necessary documentation is completed or requested before the patient visit

·       Collaborate with the patient and patient’s care team to develop an individualized treatment care plan

·         Utilize clinical acumen to facilitate internal and external resources to coordinate the individualized plan of care

·       Advocate on behalf of patients and families to facilitate resources

·       Identify barriers and resulting opportunities for intervention

·       Routinely assess patient’s status and progress towards goals; adjust care plan as needed

·       Use technology to assist with all aspects of care to include electronic medical record documentation, disease registry, documentation prompts, standing order protocols and others to address issues such as patients that are overdue for care, services, testing and/or screening

·       Oversee the preventive care reminder processes for the clinic’s patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing, including point of care reminders

·       Document all interactions with the patient in the EHR and provide the patient with a walk-out Plan of Action at the end of the visit, as applicable.

·       Assist patients in setting goals for self-management by teaching them how to do self-management tasks and when to report abnormal findings

·       Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals;

·       Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments; facilitate appropriate resources/ referrals as needed

·       Ensure a smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physicians, or by another health care provider

·       Maintain collegial relationships with community resource agencies and connect patients to the appropriate resources as needed

·       Actively engage patients in activities to improve their health

·       Create a collaborative relationship with the patient in the management of their health care status through education plans related to health preserving, disease prevention, and disease self-management interventions

·       Refer patients to other entities for education as needed

·       Assist patient with the procurement of medical supplies when necessary

·       Contact patient between visits to assess patient progress toward health status goals

·         Oversee the development, procurement, and adoption of patient self-management educational resources used by the practice providers

·         Supervise, collaborate with and instruct the CTA in obtaining required clinical data necessary to support effective care coordination

·         Attend all required safety training programs and is knowledgeable of his/her responsibilities related to general safety, department/service safety, and specific job–related hazards.

·         Adhere to Legacy’s exposure control and blood-borne/airborne pathogens plans.