Bilingual RN Care Coach - Bonus Eligible

Current, unrestricted Multistate RN or New Mexico RN license. Fluent in English and Spanish. Proficiency with EPIC electronic health record and web-based applications (highly preferred). 3+ years' experience as a Registered Nurse. Case Management or Chronic Disease Management experience (highly preferred). Certified Diabetes Educator (preferred). Experience with Motivational Interviewing or other behavior change communication techniques (preferred). STRONG internet-connected computer required. Minimum of 20 hours of availability per week between 8 am and 5 pm MST, Monday-Saturday.

Utilize care management software to call Medicare patients with chronic conditions monthly. Build rapport with patients, coach them to improved health using SMART goals and self-management strategies. Implement and improve the Plan of Care by updating medications, appointments, biometrics, symptoms, and interventions. Connect patients with community resources. Conduct Transitional Care Management for high-risk patients discharged from the hospital/ER. Close care gaps by encouraging preventive care measures.