Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Roles & Responsibilities:
1) Collaborates with primary care physicians, specialists, practice management, and payers to identify and develop a registry of moderate to high risk patients.
2) Develops and utilizes a tracking system for patient care coordination, documentation sharing and care management across the continuum between PCP and specialist, emergency room, hospital and/or other providers, supporting referrals, test completion, report receipt, and an integrated plan of care.
3) Facilitates coordination and smooth transitions of care between health care providers and facilities to reduce the likelihood of unnecessary, repetitive testing, re-admissions and related complications.
4) Provides oversight of the care coordination system for medium-high risk patients managed by the practice team
1) Experience in case management, disease management, home health care nursing, hospital nursing or intensive outpatient education and self-management support (i.e. CDE).
2) Education: Registered Nurse with BSN (minimum)
a. Comprehensive nursing assessment, problem identification and care plan development
b. Disease management
c. Triage and health screening skills
d. Clinical system design and development
e. Project management
f. Behavioral strategies including motivational interviewing and self-management support
g. Relationship building with patients, staff, and providers
h. Management of staff
i. Documentation in an EMR
j. Computer skills including excel, word, and PowerPoint,
4) Working conditions: PCP office based with the ability to do home visits on a limited basis
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression.