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Job description
Job Title
Lead patient centered case management for patients with chronic and complex health conditions by conducting comprehensive assessments and developing individualized care plans that improve health outcomes and continuity of care.
Coordinate care across providers, specialists, community programs, and external healthcare facilities to ensure seamless, timely, and effective delivery of services.
Provide direct professional nursing care through in person and telehealth encounters, monitor patient progress, and intervene early to prevent complications and hospital readmissions.
Educate and empower patients and families using culturally appropriate methods to support disease management, treatment adherence, and self-management.
Analyze patient outcomes and care gaps and collaborate with interdisciplinary teams to improve care coordination processes and overall program effectiveness.
Worksite address
lockport, NY, 14094, US
Who can apply
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