Under limited direction and according to established policies and procedures, provides care coordination services to patients, families or post acute care givers. Patients appropriate for services may have acute or chronic conditions including, but not limited to, Diabetes, Cardiac Arrhythmias, Coronary Artery Disease, CHF, COPD, Recent Stroke, Short or long term anticoagulation or Renal Failure. Functions as a facilitator of inter-disciplinary collaboration across care transitions. Coaches target patient populations and their caregivers to assume an active role in the formation and execution of a plan of care, encourage self management, and assist in coordination of communication between the patient, caregivers and primary care providers. Assesses patient and family understanding of di
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