Job Overview: This position provides comprehensive care coordination supporting a holistic and longitudinal approach across the continuum related to specific episodes of care. This position assists with informed decision making, collaborating with a multidisciplinary team to allow for timely screening, intervention, and increased supportive care throughout the patient experience. Job Requirements: Associate's Degree in Nursing Equivalent experience accepted in lieu of degree RN Registered Nurse minimum 1 year experience Clinical Nursing Experience in home care or Care Collaboration preferred Job Responsibilities: Assesses patient plan of care and develops, implements, monitors, and documents utilization of resources and progress of the patient through their care, facilitating options and services to patient's healthcare needs. Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Serves as a liaison for referring physicians and connections to community resources. Assesses clients'/caregiver(s)' activation, literacy level and self-management capabilities. Evaluate patient functional abilities and limitations. Determine if intervention is needed Educates client and family/caregiver(s) on diagnosis,course of care, medication, medication reconciliation and nutrition and moves client toward self-management Reviews and analyzes model of care clinical pathway process improvement activities for appropriate populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Provide support for data collection and reporting, as needed, for value based contracts. Other Job-Related Information: Working Conditions: Climbing - Occasionally Concentrating - Frequently Continuous Learning - Frequently Hearing: Conversation - Consistently Hearing: Other Sounds - Consistently Interpersonal Communication - Consistently Kneeling - Rarely Lifting TriHealth is an equal opportunity employer. We are committed to fostering a diverse and inclusive workforce.