<p>SUMMARY: Ensures consistent high-quality nurse care management of complex patients in an effort to reduce unnecessary utilization. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate RESPONSIBILITIES: Identification and assessment of the rising-risk and high-risk patient population Identifies the targeted rising-risk and high-risk population within practice site(s) per Primary Care Provider (PCP) referral, risk stratification, and according to an established high-risk definition Identifies hospital-based patients and overviews care management and safe discharge planning, including identification of barriers on morning conference call with interdisciplinary care teams Development, implementation and updating of care plans Manages a panel of high-risk patients to establish care management plans, interventions, treatment goals and self-management goals Develops care plans for patients upon admission into high-risk care management program and updates quarterly Encourages and supports high-risk patients to maintain adherence to their care plans Coordination of patient care Assesses the healthcare, educational, spiritual, social and psychosocial needs of the patient/family Determines individual patient needs for services, referrals and training and provides patient education pertaining to health status, medications, discharge planning, safety and other needs Assisting patients with self-management through in person education and telephonic engagement Conducts ongoing assessments both in person and telephonically, coordinating care conferences with providers, and collaborating with the healthcare team Assists patients in navigating the healthcare system Engages high-risk patients to actively manage their health Assesses readiness for complex care conversations with patients and families Collaboration with the practice and specialty care teams Collaborates patient care with PCP and all members of the healthcare team, including any required health care services outside of Brown Health Medical Group Primary Care Ensures open communication regarding patient status with physicians, office staff, BHMGPC centralized clinical services and patients' families Identifies and utilizes cultural and community resources Acts as liaison to hospital, long-term care, specialists and home health representatives Attends required trainings and practice team meetings as scheduled Mentors Care Navigator and actively supports role development and scope of practice Complies with federal and local confidentiality laws, including HIPAA, ensuring patient privacy Adheres to Brown Health Medical Group Primary Care guidelines for protecting patients' demographic, clinical and financial information Performs other miscellaneous job-related duties as assigned MINIMUM QUALIFICATIONS: Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.</p> <p>Pay Range:</p> <p>$78,748.80-$157,476.80</p> <p>EEO Statement:</p> <p>Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.</p> <p>Location:</p> <p>Brown Health Medical Group Primary Care - 593 Eddy St - Executive Suite Providence, Rhode Island 02903</p> <p>Work Type:</p> <p>M-F 8:00-4:30</p> <p>Work Shift:</p> <p>Day</p> <p>Daily Hours:</p> <p>8 hours</p> <p>Driving Required:</p> <p>Yes</p>