Company DescriptionA faith based charitable clinic providing quality medical care and healing to those most in need, regardless of ability to pay.North Coast Health is a charitable health care clinic, providing medical care to people with low or no income-with or without insurance.North Coast Health provides:* Medical appointments* Prescriptions assistance * Care for diabetes, high blood pressure & other conditions* Assistance applying for health care coverage, and moreNorth Coast Health received a level 3 patient-centered medical home recognition from the National Committee for Quality Assurance (NCQA); the highest recognition that is awarded.Job DescriptionSchedule/Hours: 30-40 hours/week; flexible, subject to Clinical Director's approvalReport to: Clinical DirectorPosition Summary: Full-time (40 hrs. per week) or Part-time (30 hrs. per week) optional. Provides self-management education and care coordination for patients with, or at high risk for, chronic disease including but not limited to- diabetes, hypertension, COPD, heart failure, depression.Position Details:Serves as a member of the patient-centered care team, providing care coordination in accordance with the patient's individual care plan, consistent with evidence-based guidelines, and in regular consultation with the providers and other members of the care team.Participates in daily huddle to review schedule and assign follow-up tasks as necessaryActive involvement in the development of the patient's care plan and follow-up, including patient self-managementCommunicates with patients in person, email, or other approaches to facilitate care coordinationDocuments all communications with the patient and records patients' progress in the electronic medical record.Designs or identifies, and implements patient education programs and materials to assist in self-managementWorks to connect patients to appropriate community resources based on patient needParticipates in training on evidence-based approaches to patient self-management, population management and effective patient communicationParticipates in quality improvement, including identifying areas for improvement based on performance measurement and patient survey dataOversees duties and functions of clerical and medical assistants as assigned by clinical directorWork with a compassionate teamQualificationsRequired Qualifications:Education: Bachelor of Science in Nursing with relevant experience; will consider associate prepared registered nurse with 5-10 years of experience.Experience: a minimum of two years' experience caring for patients with chronic disease, especially diabetes and hypertension; experience working as a team member to coordinate care with the patient and the patient's family; experience as a patient educator; familiarity with electronic medical records.Licensure/Certification: Current Ohio license as Registered NurseDesired Qualifications/Abilities:Experience working in a clinical environment; interest in serving a vulnerable population; understanding of and commitment to evidence-based practices and quality improvement; understanding of and/or experience working in a patient-centered medical home practice highly desirable.Additional InformationHours flexible 30 - 40 hrs