Wellness Coordinator Prn- Registered Nurse

Support and participates in the Patient-centered Medical Home (PCMH) concepts of team- based care.

Assess, plan, implement, coordinate, monitor and evaluate healthcare options and services with the goal of increasing the likelihood of improvement to the health status of identified populations across the continuum.

• Delivering direct patient care in primary care office
• Perform Nurse Triage for patients calling the office
• Perform all direct patient care within the scope of an RN
• Participate in PCMH activities which include but are not limited to: hospital discharge follow-up, care planning, coordination of services, and communication between care providers
• Collaborate with patient’s medical/health and community-based providers to establish mutual goal-setting including patients and their families/caregivers, utilizing self-management tools.
• Provide outreach, care management and education for disease self-management per patient centered goals.
• Identify, document, and mitigate patient barriers to improved outcomes.
• Conduct assessments, develop nursing treatment plans and interventions and set goals for treatment plans/behavioral modifications within the scope of licensure in collaboration with other care providers.
• Assists physicians and other team members in developing and implementing evidence based practices and care plans for target health populations.
• Collect data on quality metrics and track as required for improvement efforts.

Participate in process/quality improvement initiatives to achieve targets as defined by organizational/department goals and objectives.