Registered Nurse - Care Coordinator

Mondays

4:30 pm

Reports to:  Operations Manager

Job Status:  Full-Time

FLSA Status:  Non-Exempt

Positions Supervised:  None

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Position Summary: 

The Care Coordinator works in collaboration with the primary care provider and all members of the health care team. Accepts referrals and manages assigned caseload. Develops care initiatives to assess and coordinate chronic disease care management for their patient population in manner that is medically appropriate and cost effective. Responsible and accountable for direct and indirect patient care for designated patient populations. Assesses healthcare needs and identifies community resources. Serves as patient advocate and assists in identification and improvement of service delivery. This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. The nurse also serves as a clinical resource to other clinical staff.

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Essential Functions:

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions. 

• Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.

• Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients in the chronic disease registries, recent discharges, and those in care transition to promote adherence to physician/provider recommendations and instructions.

• High risk and chronic disease management by registry/referral including:

  • Provide nursing care via face-to-face, telephonic and/or electronic communication.

  • Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.

  • Address medication adherence.

  • Provide education to patients regarding health conditions.

  • Collaborate in goal planning and care management.

  • Communicate changes in patient’s status appropriately with the care team.

  • Identify barriers when treatment goals are not met, treatment plan is not being followed or important appointments are missed.

  • Identify patients who are overdue for visits, labs and referrals, contact patients and arrange for follow-up services.

  • Assist the patient in improved healthcare access and promote patient knowledge of health and behavior change.

  • Facilitate the initiation of diagnostic services, treatment planning and therapeutic treatment while the patient is enrolled in the program in the practice setting.

• Utilize appropriate protocols and standing orders in delivering patient care.

• Serve as a clinical resource and community referral resource within the practice.

• Assist providers with shared medical appointments and group visits.

• Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.

• Follow-up with assigned patients on all labs, tests and consults to ensure work is done.

• Document all communication with patient in electronic medical record.

• Perform all other duties as assigned.

Competencies:

• Ability to work independently and exercise clinical judgment in interactions with physicians, payers, patients and their families.

• Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.

• Strong analytical and data management skills.

• Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources.

• Communication – Ability to communicate effectively verbally and in writing. Excellent negotiation skills.

• Computer Skills – Proficient ability to use a computer and electronic medical record.

• Confidentiality – Maintain patient, team member and employer confidentiality. Comply with all HIPAA regulations.

• Customer Service Oriented – Friendly, cheerful and helpful to patients and others. Ability to meet patients and others needs while following office policies and procedures.

• Decision Making – Ability to make critical decisions while following CVFP policies and procedures.

• Flexibility – Ability to adapt easily to changing conditions and work responsibilities.

• Positivity – Display a positive attitude and is a positive agent for change.

• Project Management – Ability to organize and direct a project to completion.

• Teamwork – Work as part of a team and collaborate with co-workers.

Education and Experience:

• Bachelor’s Degree preferred

• Two years of nursing experience

• Experience with utilization review and discharge planning required

Certification and Licensure:

• Active Registered Nurse License

• CPR Certification required

• Registered Dietitian (preferred but not required)

Work Environment:

• Environmentally controlled medical office environment

• Fast paced environment with occasional high pressure or emergent situations

• Work hours subject to office needs to ensure coverage during all hours of operation

• Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public

Physical Demands:

• Frequent sitting, standing, walking, grasping, carrying and speaking

• Occasional reaching, bending and stooping

• Lifting, carrying, pushing and pulling up to 60 pounds, with assistance if needed

• May need to lift or turn patients who are disabled, with assistance if needed

• Frequent use of computer, keyboard, copy and fax machine and phone

• Occasional travel to attend meetings or trainings

Registered Nurse - Diabetic Educator

Tuesdays

10:00 am

Reports to:  Operations Manager

Job Status:  Full-Time

FLSA Status:  Non-Exempt

Positions Supervised:  None

Job Summary

Perform professional nursing, consultation, and educational services for persons with diabetes, and provides community health education. Develop curriculum on health, including research and production and act as a health care consultant by providing information on the management of diabetes for patients.
 

Essential Functions

• Promote the mission, vision, and values of the organization

• Provide education related to diabetes and the disease process; medication, diet and nutritional monitoring; foot care, prevention and care of complications; blood glucose monitoring and the techniques of self-monitoring and injection

• Develop and implement educational programs for diabetic staff, patients, and families

• Advise patients as to long-term complications

• Provide clinical resource and consultation to staff and physicians

• Assist patients in monitoring blood glucose for the purpose of medication control and adjustment for both insulin and non-insulin dependent diabetics

• Assess, monitor and implement treatment plans for patients at various stages of the disease. The focus is on prevention of complications and management of stable diabetes

• Provide ongoing assessment and recommendations to the treatment team and patient/family for adjustments in the plan of care as required

• Document assessments, interventions and plans including recommendations and goals, progress notes and discharge summaries

• Coordinate community outreach education classes to include the schools

Non-Essential Functions

• Perform other duties as assigned

Professional Requirements

• Complete annual education requirements.

• Maintain patient confidentiality at all times.

• Report to work on time and as scheduled.

• Wear identification while on duty.

• Maintain regulatory requirements, including all state, federal and local regulations.

• Represent the organization in a positive and professional manner at all times.

• Comply with all organizational policies and standards regarding ethical business practices.

• Communicate the mission, ethics and goals of the organization.

• Participate in performance improvement and continuous quality improvement activities.

• Attend regular staff meetings and in-services.

Qualifications

• Bachelor’s Degree in Nursing

• Clinical Social Worker (LCSW) or Registered Dietitian / Nutrition Professional preferred

• A minimum of two years’ experience as a Registered Nurse

• Bilingual preferred

Knowledge, Skills, and Abilities

• Knowledge of diabetic education services

• Strong organizational and interpersonal skills

• Ability to determine appropriate course of action in more complex situations

• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude

• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work

• Ability to maintain confidentiality of all medical, financial, and legal information

• Ability to complete work assignments accurately and in a timely manner

• Ability to communicate effectively, both orally and in writing

• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

Work Environment:

• Environmentally controlled medical office environment

• Fast paced environment with occasional high pressure or emergent situations

• Work hours subject to office needs to ensure coverage during all hours of operation

• Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public

Physical Demands:

• Frequent sitting, standing, walking, grasping, carrying and speaking

• Occasional reaching, bending and stooping

• Lifting, carrying, pushing and pulling up to 60 pounds, with assistance if needed

• May need to lift or turn patients who are disabled, with assistance if needed

• Frequent use of computer, keyboard, copy and fax machine and phone

• Occasional travel to attend meetings or trainings