Job Details Develop and maintain daily active patient tracking mechanisms using available reports and customize spread sheets. Visit patients with identified diagnoses, CHF/Heart Failure, Pneumonia, COPD, who meet readmission criteria and those patients identified as high risk for readmission. Review and distribute select resource material to patients and families as appropriate, i.e., LIHN Disease Specific Booklets. Maintain accuracy of resource material through networking and internet research. Serve as a liaison between patient and all other care providers, including physicians, home care agencies and skilled nursing facilities as appropriate. Assess patients for financial, physical or psychosocial barriers, including health literacy. (Tools TBD) Follow patients through the care continuum and collaborate with the treatment team to provide a safe and effective discharge plan. Work in conjunction with Care Coordination Administrative Assistant to schedule post discharge appointments with Primary Care Physician or identified specialists within 48 hours of discharge. Makes follow up phone calls to patient as appropriate to monitor compliance with plan, medication adherence, diet understanding and compliance with physician follow up. Attends ICC Rounds for high risk readmission patients as appropriate. Identify and present process improvement opportunities related to scope of work and help plan and initiate changes. What you’ll bring: 5+ Years of RN experience working in an acute care hospital Experience in Care Management preferred Skilled in the use of electronic medical record (EMR), MS Office, MS Excel, & MS PowerPoint Education: Graduate of an accredited School of Nursing required Licensure: New York Registered Nurse (RN) License & Registration Salary Range USD $53.01 - USD $70.28 /Hr.