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City:  Cincinnati
State:  OH
Job Requisition Number:  164901

Attention current TriHealth employees:

Please apply for this position by submitting an online internal application via SuccessFactors. Please be certain to update your SuccessFactors Employee Profile prior to applying to this position.


Facilitates advanced management of care to an identified high risk client population. Demonstrates clinical expertise through direct or indirect care. Coordinates patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes. As a collaborating member of the health care team provides pre-visit and follow-up direction and support to the patient, family, and health care providers. A large portion of care will be provided telephonically.

The responsibilities will include:

• Participates in our patient-centered medical home, aiding in the development of office workflows for the medical home, and collaborating with physicians to developing a standard of care with preventative services and chronic disease management.

• Participating in clinical quality activities and facilitateing implementation of clinical best practices.

• Managing transitions of care between the inpatient and ambulatory settings. Actively manages assigned panel of patients with multiple chronic conditions.

This includes:

• Developing relationships with patients as an integral team member.

• Providing follow-up contact with patients as indicated to ensure compliance with recommendations – medications, lab/x-ray, specialist visits, PCP visits, dieticians, etc.

• Providing telephone advice per protocol, handling urgent calls and emergent calls.

• Assisting patients in setting goals for self management, teaching them how to do self management tasks, and reporting abnormal findings to their physician team.

• Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments.

• Coordinating care with hospital, ER, consulting physicians, and community resources. Develops and documents workflow for the PCMH delivery model and the reporting of outcomes.

This includes: • Participating with project team and Performance Improvement staff to develop and document workflows and protocols for the delivery model.

• Educating clinical staff on quality improvement protocols and plans.



EDUCATION: Graduate of an approved technical, professional, or vocational program Nursing Other LPN Licensed Practical Nurse

EXPERIENCE: 2-3 years Clinical Nursing 2-3 years Clinical Nursing Physician Office Experience

SPECIALIZED KNOWLEDGE: Strong oral and written communication skills. Customer service skills. Ability to work with physicians and other professional colleagues. Ability to collect data, generate reports, and provide analysis. Comfortable working with computers and with EMR..


Department Name:  TRIS AMB CARE COORD

Location:  Baldwin

Hourly/Salaried:  Hourly

Employment Status: Full Time Position

Bi-Weekly Hours:80

Shift: Day Shift

Weekend Commitment:  No

Holiday Commitment:  No

On-Call Commitment:  No

Nearest Major Market: Cincinnati

Job Segment: Medical, Medical Lab, Patient Care, Nursing, Healthcare