LISTING: Temp-to-hire Full time Disease Management nurse, Chicago, IL
Our client, an ACO located on the near west side of Chicago, is seeking an experienced Disease Management Nurse. The main purpose of this position is to provide a comprehensive assessment of patient risk and needs for education, discharge planning and resource needs during an episode of illness and across the continuum of care
- Directs the patient throughout the system by coordinating care with the PCP, physician, direct care staff, interdisciplinary team which includes the patient and family; arranges for a PCP for patients who do not have an existing relationship
- Streamlines transitions in and out of the hospital, speeds up referrals and ensures prompt scheduling of follow-up appointments taking in to consideration patient preference and schedule; reinforces discharge plan and compliance.
- Works with the interdisciplinary team, develops and implements disease specific protocols and order sets for the entire continuum of care based upon the latest evidence-based recommendations.
- Develops effective working relationships with PCPs, Specialists, care team members, home health agencies, SHS administrative leadership, medical leaders, SCI and SUHI program staff, clinic networks, and other support organizations.
- Assures that an appropriate plan of care is created and documented for the patient..
- Assess and document patient’s readiness to change and self-management abilities; provides teaching to the patient that provides them with information that is comprehensive and culturally appropriate; employs advanced teach-back methods.
- Coordinates the creation of the After-Hospital Discharge Plan.
- Contacts patients post discharge/ office/clinic visit to assess continued knowledge of disease.
- Maintains appropriate documentation on activities/discussions with patients in the approved disease management record/system.
- Develops and maintains excellent working knowledge of disease management/care management/health coaching skills and systems.
- Associate or Bachelor’s degree in Nursing required; if incumbent has an Associate’s, Bachelor’s in Healthcare related field required. Master’s Degree strongly preferred.
- Minimum five 3-5 years’ experience in a related clinical nursing position. Prior experience in disease management/care management/health coaching highly desirable.
- IL RN license required; Disease Management Certification desired.
KNOWLEDGE & SKILLS:
- Demonstrated knowledge and experience in management of disease processes
- Demonstrated knowledge of disease management/care management/health coach processes
- Demonstrated ability to develop and employ effective patient teach back methods
- Demonstrated knowledge of facilitating and coordinating patient care plans
- Excellent oral, written, and interpersonal communication skills. Ability to work independently and also as a team with a wide variety of individuals; Excellent organizational skills
- High degree of creativity in problem-solving; ability and patience to navigate and impact complex systems of care.
- Proficient computer skills & Willingness to work some weekends
If you or anyone you know is interested, qualified and available please send resume to us for immediate consideration.