Registered Nurse
Company: Community Health Connections, Inc.
Location: Fitchburg
Posted on: May 16, 2022
|
|
Job Description:
the Care Coordinator performs an integral role in the team-based
approach to care, developing collaborative relationships with
providers, patients and their significant others and other members
of the care team. He /she ensures that high risk patients receive
care that is consistent with national, state and health center
standards and policies. The Care Coordinator supports patients and
families in self-management, through evidenced-based approaches as
appropriate, engages in health center projects aimed at specific
patient population needs, and utilizes effective and appropriate
communication strategies for issues such as health literacy and
cultural norms when working with patients. The RN Care Coordinator
partners with Care Coordination Specialists and interpreters to
ensure that patients are able to access culturally and
linguistically appropriate services in a timely and cost effective
manner. He/she participates in performance improvement initiatives
and demonstrates the use of quality improvement in daily
operations. Essential Duties and Major responsibilities: Completes
an initial assessment actively involving the patient to determine
care coordination needs, Utilizing motivational Interviewing
techniques, creates and updates care plans which address identified
needs and emphasizing patient specific goals and self-management as
they relate to desired medical outcomes. Partners with patient to
encourage active participation in identifying patient's own goals
Utilizes a collaborative approach with the PCP and other team
members in creating the comprehensive action plan to help ensure
that the patient receives a consistent message from all team
members. Utilizes behavioral strategies to assist patients in
adopting healthy behaviors, improving self-care and managing
chronic disease with a focus on educating and optimizing the
member's/families level of independence in navigating the
healthcare system at all levels of the continuum Plans,
coordinates, monitors and, evaluates progress toward meeting goals
in the plan of care Serves as a liaison and patient advocate
between the providers, health center, and community resources to
facilitate access to services and improve the quality of the
services delivered. Educates patient on and/or assist with
establishing advanced directives Integrates the patient/family
members into care coordination and care management planning and
communications, assuring the patient/family are informed and
supported in decision-making. Provides ongoing verbal and written
communication of patient's needs, plan of care, progress and
changes in status with the PCP, team and the patient/family through
comprehensive physical, mental and psychosocial assessments
Executes medical orders for specific drugs, treatments, and other
diagnostic or therapeutic procedures Administers and records
medication administration consistent with his/her knowledge of
pharmacology in accordance with health center policy Administers
routine vaccines when not administered as part of office visits.
Knowledgeable of current and catch up vaccine schedules & complies
with vaccine storage guidelines as set by the MA DPH Participates
in preventive health teaching and education pertinent to procedures
being conducted Working with the primary care provider and other
members of the care team, plans and coordinates and related
complications for the transition care of patients discharged from
the hospital within 48 hours to prevent readmission Under the
direction of the PCP, manages tracking systems and care plans for
patients admitted to and any other health care facility with the
objective of preventing further disease exacerbation, improving and
ER utilization outcomes, increasing patient engagement in self
-care, decreasing risk status, and minimizing hospital discharged
from the hospital, patients seen the emergency room, and patients
transitioning from or to Identifies and manages the patient's
primary driver (reason or problem that caused the hospitalization
or ER visit) and under the PCP's direction, assists/coordinates
patient care in problem solving issues related to the health care,
financial and psychosocial barriers. Serves as a resource to
non-clinical staff regarding clinical issues (i.e. phone triage)
Attends department meetings and any mandated continuing
education/training programs Maintains working knowledge of PCMH and
the current requirements Demonstrates analytic and data management
skills using a variety of PC based software, including MSOffice,
Word, Excel, and Power Point) Demonstrates understanding and
commitment to the mission of the health center, and established CHC
values and standards Adheres to established organization policies
and procedures Perform related duties as required and assigned.
Qualifications: Current MA RN licensure as Registered Nurse.,
Bachelor of Science Nursing preferred Experience in health
education or care management preferred Clinical experience with
patients with chronic disease a plus. Proficiency with Electronic
Health Records (EHR.) Bilingual in Spanish or Portuguese preferred
AHA BLS Health Care Provider certification Excellent critical
thinking and problem solving skills with attention to details
Demonstrated interpersonal relationship skills Demonstrated written
and verbal communication skills in English Demonstrated ability to
work in a fast paced medical office environment Employment Type:
Full Time Bonus/Commission: No
Keywords: Community Health Connections, Inc., Nashua , Registered Nurse, Healthcare , Fitchburg, New Hampshire
Click
here to apply!
|