HOME VISITING NURSE LIAISON

CARE  MANAGEMENT DEPARTMENT     DAY SHIFT  

Jamaica Hospital Medical Center currently seeks F/T experienced Home Visiting Nurse Liaisons with current New York State license to work in our Care Management Department.  Responsible for advocating and providing assistance for patients. Duties include, but are not limited to:

• Responsible for administration of Transition of Care and Complex Case Management services for our clinically complex, high-risk patients recently discharged from the hospital or referred by PCP and/or other sources.
• Facilitating PCP engagement and follow-up post hospitalization
• Performing full assessment of patients’ clinical status, safety, and Health Related Social Needs in the patient home (Queens and Brooklyn only).
• Developing a person-centered care plan based on assessment findings and managing overall clinical and bio-psychosocial needs of patients within nursing scope of practice.
• Utilizing EMR data and other sources to perform full medical record reviews and formulate patient health status and gaps in care.
• Administering disease management education to patients with chronic conditions
• Effectively collaborating with patients, caregivers, Medical Advisors, PCP, and other specialist community entities to ensure individualized care and completion of care plan goals.
• Educating and guiding patients on disease prevention and healthy lifestyle habits.