JOB TITLE: Registered Nurse/Clinical Lead/Care Coordinator

GENERAL STATEMENT OF DUTIES: Provides professional nursing care under supervision for clinic patients and manages defined at risk populations and coordinates care through quality team processes while leading and managing staff.

ORGANIZATIONAL RELATIONSHIPS: Reports directly to the Practice Manager.

ESSENTIAL JOB FUNCTIONS:

Duties performed in this RN role include but are not limited to the following:

1. Performs general nursing care to patients. Administers prescribed medications and treatments in accordance with nursing standards as directed by physician or nurse practitioner.

2. Assists with the preparation of equipment, and aids physician/nurse practitioner during treatment, examination, and testing of patients.

3. Observes, records, and reports patient’s condition and reaction to drugs and treatments to physicians. Administers prescribed medications as directed.

4. Oversees appointment bookings and ensures preferences are given to patients in emergency situations. Maintains timely flow of patients.

5. Greets patients and prepares them for physician examination. Screens patients for appropriate information. Instruct patients in collection of samples and tests.

1. Arranges for patient testing and admissions.
2. Responds to and refers incoming telephone calls. Instructs patient and family regarding medication and treatment instructions.
3. Implements providers care plan and updates as necessary. Orders, prepares, and inspects patient’s charts. Posts test and examination results.
4. Responsible for preparation of exam rooms including re-stocking of treatment areas.
5. Attends required meetings and participates in committees as requested.

11. Participates in professional development activities and maintains professional affiliations/licensure requirements.

12. Maintains patient confidentiality.

13. Performs related work as required per department. (See required duties specific to department.)

14. Comply with all statutory and regulatory policies and procedures

15. Teaches patient education

16. Delegates job duties.

17. Updates health maintenance

18. Double checks medications and immunizations.

Duties performed as clinical lead include but are not limited to the following:

1. Creates work schedules for staff.
2. Maintaining timecards/variances in Kronos.
3. Leads clinical team in patient care/problem solving.
4. Responsible for ordering medical and/or clerical supplies.
5. Responsible for maintaining inventories on vaccinations and injections.
6. Delegates job duties.
7. Attend management/coordinator meetings and other meetings as required.

Duties performed as Care Coordinator include but are not limited to the following:

The AMG PCP Care Coordinator manages defined populations by using a collaborative process of assessment, planning, implementation and evaluation, to engage, educate, and promote/influence patient decisions related to achieving and maintaining optimal health status on behalf of the primary care provider and/or practice. The Care Coordinator uses a combination of proactive telephone calls, hospital, physician office and home visits to patients who are established patients in the Practice and recognized as needing care management. The Care Coordinator develops ongoing supportive relationships with all members of the Care Team and beneficiaries. The Care Coordinator is the primary intermediary that assists in care coordination to better assist the patient navigate the healthcare system, physicians address the care gaps identified, and the office administrative staff collect relevant data points to share among insurers, medical homes, and accountable care organizations.

Responsibilities & Expectations:

• Ensures consistent use of an initial Health Risk Assessment (HRA) for patients deemed eligible for care coordination.
• Conducts initial visit with more comprehensive HRA if needed, to detect level of care coordination/management needs.
• Understands the role and use of clinical protocols and standing orders for chronic disease management.
• Uses other team members as appropriate to co-manage.
• Works with patients and providers in the creation of a care plan, or in review and update if there is an existing care plan.
• Uses a variety of education materials, brief intervention techniques, and community resources to engage patients, increase their motivation to change, and support patients in establishing behavior change goals and implementing plans to meet those goals.
• Establishes a follow-up schedule and monitors patients’ progress.
• Effectively and accurately uses Electronic Health Records (EHR) to document and track patient history.
• Maintains accurate and up-to-date records and standardized data on all patients.
• Clearly and effectively communicates with the patient, PCP, and any external providers, including information from the PCP about the patient’s progress and discussing side effects and care plan with the PCP and other care team members as needed.
• Develops a maintenance plan with patients, when appropriate, to help them maintain a healthy lifestyle and prevent a reoccurrence of symptoms of their chronic condition(s).
• Collaborate with care teams to implement evidence based protocols and methods for primary care patients.
• Through HRA assigns a risk score and updates this risk score in the HER.
• Other duties as assigned.

KNOW HOW: Knowledge of the principles and skills needed for practical nursing to provide patient care and treatment. Knowledge of examination, diagnostic, and treatment room procedures. Knowledge of medications and their effects on patients. Knowledge of patient education principles to develop a self-care program. Knowledge of common safety hazards and precautions to establish a safe work environment. Skill in administering a variety of treatments and medications as directed. Skill in using various types of equipment for examination and treatment procedures. Skill in taking and documenting vital signs. Skill in maintaining records and writing reports. Skill in establishing and maintaining effective working relationships with patients, medical staff, and the public. Ability to maintain quality control standards. Ability to recognize problems and recommend solutions. Ability to react calmly and effectively in emergency situations. Ability to interpret, adapts, and applies guidelines and procedures. Ability to communicate clearly. Knowledge of timekeeping software, managing staff, supply ordering, coordinating with other departments i.e. IT, lab, etc. to provide exceptional and seamless patient care. Knowledge of risk assessments and ability to develop ongoing relationships with patients and their family members to foster better care. Ability to understand reporting quality measures and how to ensure these measures are captured for reporting purposes, teaching staff in office and other care coordinators how ensure these measures are captured in the EHR. Drives quality initiatives directly impacting performance.

TYPICAL PHYSICAL DEMANDS: Requires full range of body motion including handling and lifting patients, manual and finger dexterity and eye-hand coordination. Requires sitting, standing, and walking for extensive periods of time. Requires occasional lifting and carrying of items weighing up to 100 pounds. Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours. Requires exposure to communicable diseases or bodily fluids.

TYPICAL WORKING CONDITIONS:Frequent exposure to communicable diseases, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

SPECIAL FACTORS: Some overtime hours may be required to accommodate patients.

PERFORMANCE REQUIREMENTS:

Must be a Registered Nurse. The RN has a great deal of contact with patients and must be able to establish rapport with them if efficient and effective care is to be rendered. The position requires a person who is tactful, understanding and sympathetic in his/her relationship with the patient. The candidate must have the ability to recognize serious problems when triaging calls and know how to get the patient serviced in a timely fashion using the resources available. The nurse must have working knowledge of record keeping requirements of the AMG, both medical and administrative. A properly qualified individual will need approximately 3 months to become familiar with the duties and with individual physician preferences.

Problem Solving: Judgement is required when dealing with different personalities of both patients and the medical staff. The RN’s duties are almost always performed within previously established AMG policies/guidelines and physician/nurse working relationships. The nurse may work independently at times or under the direct supervision of the physician/Nurse Practitioner. Depending upon their nature, difficult or unusual problems can be referred to the physician, nurse practitioner or practice manager. Has the ability to assess staffing concerns and implement fixes. As care coordinator knows the patients and has the ability to affectively assess and lead the patient to better outcomes.

Accountability: The RN is accountable for all nursing care that he/she renders to the patient or should have rendered to the patient. The RN must follow the physician’s/nurse practitioner’s instructions explicitly when providing care of any kind to patients. The nurse is responsible for dealing with patients in a friendly and cooperative manner. The RN must make accurate decisions regarding the potential severity of problems telephoned to him/her by patients and must consult the physician/nurse practitioner in a timely fashion regarding those problems. The nurse is required to use supplies and materials only as needed to avoid wasting supplies and materials. The nurse is also required to see if other departments can use supplies not yet used that are close to expiration. The outpatient/ambulatory nurse is an integral part of patient care at the Foundation. As Clinical lead he/she is accountable for staffing in the office as well as staff education/performance, office and medical supplies, supporting the practice manager. As care coordinator he/she is responsible for assessing high risk patients, following up with them after ED visit or hospital admission, ensuring providers are meeting quality initiatives and the proper input into EHR.

EDUCATION: Graduation from an accredited school of practical nursing.

EXPERIENCE: Minimum 2 years’ experience with direct patient care, primary care setting preferred. Continue education for RN licensure.

CERTIFICATES/LICENSE: Valid RN license and CPR certification

ALTERNATIVE TO MINIMUM QUALIFICATIONS: None.

HIPAA Compliance: Full access to patient health information is required in this position.

Must comply with all regulatory, compliance and safety regulations, policies and procedures.