Assess current health status, socioeconomic status, resource utilization, gaps in care, past and present treatment plans and/or integrated care plans, strengths, and barriers for assigned members.
Develop, assess, and adjust care plans for assigned members as necessary to promote quality, member centered, cost-effective care.
Collaborate with and coordinate services and supports between the Primary Care Physician (PCP), specialists, medical, behavioral, and community/social service providers, as well as other key interdisciplinary team members to meet the complete medical and social needs of members.
Provide member education.
Monitor and document all member referrals to support the member’s overall care plan and ensure the member receives needed/requested services or support.
Actively participate in and present during Integrated Care Team meetings and member rounds
Identify member risk and/or quality concerns and report these to the appropriate resources.
Enter and maintain assessments, care plans, and other pertinent clinical documentation and information into various medical management systems.
Other duties as assigned by Manager.
Required Qualifications
Graduation from an accredited school of nursing.
2+ years of clinical nursing experience in a clinical or community setting.
Must reside in Georgia.
Must be licensed as a registered nurse in good standing in Georgia.