Care Team Nurse - Virtual (52361)

The Care Team Nurse – Virtual provides remote nursing support, telephonic triage, care management, chronic disease management, patient education, and clinical follow-up services for patients across an assigned region. This role collaborates with providers and care team members to improve patient outcomes, support continuity of care, promote patient engagement, and provide comprehensive nursing support through telephonic and virtual services. The position functions primarily in a remote environment and supports multiple clinic locations within an assigned region.

JOB RESPONSIBILITIES:

• Identifies, tracks and manages care for the highest risk patients.
• Perform telephone triage utilizing approved nursing protocols and clinical judgment.
• Assess patient symptoms and determine the appropriate level of care.
• Provide patient education regarding symptoms, medications, treatment plans, and preventive care.
• Respond to patient questions and concerns through telephone encounters and electronic messaging.
• Complete hospital discharge follow-up calls and transitional care activities.
• Conduct Call4Health follow-up.
• Perform Chronic Care Management (CCM) services.
• Participate in ongoing care management activities for high-risk and complex patients.
• Assist patients in understanding and following their care plans.
• Support patient engagement and closure of identified care gaps.
• Communicate normal laboratory and diagnostic results with patient education.
• Communicate abnormal laboratory and diagnostic results as directed by providers and reinforce provider treatment recommendations.
• Escalate urgent or concerning findings to providers as appropriate.
• Monitor and manage provider task boxes.
• Process medication refill requests according to approved protocols.
• Conduct Medicare Annual Wellness Visit (MAWV) preparation activities.
• Complete chart reviews and pre-visit planning activities.
• Assist with identifying preventive care and quality measure opportunities.
• Coordinate patient care activities and facilitate communication between patients, providers, pharmacies, hospitals, and care team members to ensure continuity of care.
• Collaborate with providers and interdisciplinary team members regarding patient needs and concerns.
• Maintain accurate documentation within the electronic health record.
• Support quality improvement initiatives and organizational performance goals.
• Participate in activities designed to improve patient outcomes, patient satisfaction, and operational efficiency.
• Ensure compliance with nursing standards, policies, regulatory requirements, and organizational procedures.
• All HealthLinc staff is committed to engage in quality improvement initiatives that align with and support Patient-Centered Medical Home (PCMH)
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.