Provides care coordination and planning for Outreach Clinical Programs (Healthcare for the Homeless, HIV, Hepatitis C, MAT, and Gender Affirming Care). Documents health history, performs triage, nursing assessments and health counseling, administers medications and treatments, provides clinical nursing care and assists clinic providers (physician and Advanced Practice Providers) commensurate with clinical proficiency, training and setting. Complies with clinical guidelines and protocols, administrative policies and procedures of Swope Health, state licensing and national certifying regulations, and accrediting agency requirements. Performs all other assignments as designated by Director of Nursing, and the Outreach Clinic Manager.

PRIMARY FUNCTIONS: Care Coordinator
1. Care Management
a. Care Management of Outreach Clinic and Clinical Program Patients
i. Provides general care management and coordination for patients enrolled in Outreach’s Clinical Programs such as (Healthcare for the Homeless, HIV, Hepatitis C, MAT, and Gender Affirming Care. ) This also includes shelter care coordination for patients living at community partner locations (shelters, transitional living facilities, etc.)
ii. Manages referrals and scheduling of patients for Clinical Programs including primary care
iii. Arranges referrals as needed to external specialty care or other members of the health care team at Swope Health (BH, Dental, OB/GYN, Optometry, etc.)
iv. Monitor patient follow up appointment compliance including appointment reminder calls and rescheduling for missed appointments
v. Monitoring and responding to assigned phone line
vi. Ensure patient knowledge of patient’s clinical program(s), resources, and prevention and treatment options and monitoring compliance
vii. Manage Hepatitis C Care Plans to meet PCMH requirements
viii. Manage Clinical Program patient data (i.e. Hep C Microsoft Excel Data Sheet)
ix. Submit Disease Case Reports to the Missouri Department of Health
b. Community Collaboration and Care Coordination
i. Coordinates with Medicaid enrollment and Outreach Services teams ensure and assist with enrollment uninsured patients who meet eligibility requirements
ii. Create and maintain relationships with community health nurses and partners
iii. Coordinates and manages patient referrals to other medical, social, and/or community-based services
iv. Coordinates and collaborates with internal and external departments, community partners, and stakeholders as indicated for patient care to facilitate access to services and other health providers
2. Clinical Management
a. Medications
i. Manage Prescription Assistance Programs (PAP) for uninsured patients
1. Process applications
2. Coordinated approval and medication delivery
ii. Manage Prior Authorization (PA) for insured patients
iii. Manage medication refills with the pharmacy or PAP program
iv. Assess patient’s compliance and side effect of medication
v. Provide education on clinical program(s) treatments and prevention and the prescribed and available medications
b. Screening
i. Assessing patients for need of Hepatitis C and HIV Screening
ii. Ordering confirmatory lab work per standing orders for appropriate patients
PRIMARY FUNCTIONS: Nursing
1. Perform patient triage and nursing assessment of patients according to clinic protocols and standards of nursing practice.
a. Orders lab and diagnostic work up per standing or provider orders and coordinates completion with patient.
b. Consults with patients and other providers by telephone to evaluate a patient’s condition.
c. Arranges referrals for specialty care, urgent or emergent care at the direction of the physician/provider.
d. Instructs patients in home self-care (in accordance with clinic protocols, patient education materials, and standards of nursing practice) when an immediate clinic evaluation is not necessary. Instructs and schedules patients to come to the clinic or for evaluation by provider in clinic or via telemedicine as necessary.
e. Consults with the provider when there is a question about the severity of the problem or the need for immediate attention.
2. Provides patients and family members with counseling and education regarding health promotion/maintenance, disease prevention and screening, diagnosis, treatment, and need for follow up as appropriate based on the patient’s provider’s recommendations within nursing scope.
3. Coordinates and integrates interdepartmental and intradepartmental services at Swope Health Central.
4. Knowledgeable on using PC and Microsoft Word and Excel.
5. Formulates treatment plans and documents all nursing care and treatments performed, in the medical record, dates and signs all entries.
6. Clinical Skills 
a. Performs the following procedures and meets clinical competency requirements:
i. Glucose monitoring
ii. Spirometry
iii. EKG
iv. Nebulizer treatment
v. Oxygen administration
vi. Ear lavage
vii. Dressing changes
viii. Pulse oximetry
ix. Peak flow
x. POC testing
xi. Medication and vaccine administration
xii. TB skin testing
xiii. Blood pressure monitoring
xiv. Diabetic foot exams
xv. Preventive Health
b. Administers medications as ordered and prescribed by the provider. May dispense prescription medications as ordered by provider.
c. Takes vital signs and weights, screening health history, ordering screening laboratory studies and x-rays, preparing patients for examination by physician/provider, transcribes provider orders, collect specimens and cultures for laboratory analysis.
d. Provide Basic Life Support to patients as necessary.
7. Documents patient encounters in the Electronic Medical Record, completes, and locks notes within the specified amount of time per Swope Health policy.
8. Operates as a team player, realizing and respecting each team member’s role/importance in providing positive treatment outcomes.
9. Completes all trainings and educational offerings as assigned and/or required by Swope Health by the assigned date.
10. Maintains in good standing with state licensing and national certifying bodies, active certification and licensure required for their position, and demonstrates compliance with continuing education requirements.
11. Maintains patient confidentiality and compliance standards set by Swope Health and certifying/accrediting bodies including maintaining computer security and safeguarding PHI.
12. Performs all other assignments as designated by the Outreach Clinic Director, Director of Nursing, and the Outreach Clinic Manager.
EXPECTED BEHAVIORS
• Treats all patients, staff, community partners, and stakeholders with dignity, respect, and compassion.
• Respects the chain of command when addressing concerns.
• Maintains personal hygiene and follows the professional dress code.
• Adheres to attendance policy and minimizes unscheduled leave.

REQUIREMENTS AND QUALIFICATIONS
• Education: Graduate of an accredited school of registered nursing preferred . Two years nursing experience preferred. Minimum qualification of Licensed Professional Nurse required.
• Licensure: Possesses a current, valid, and unrestricted license to practice in the State of Missouri and/or State of Kansas
• Professional Skills: Demonstrates of professional competence, ethical conduct of practice, and appropriate and respectful interpersonal skills

ACKNOWLEDGMENT
The above statements are intended to describe the general nature and level of work being performed by associates in this position. They are not intended to be an exhaustive list of all duties, responsibilities and qualifications of employees assigned to this job. By acknowledging the above job description and accepting the position, the physician agrees to abide by the stated requirements, and will perform all duties and responsibilities delineated.