Registered Nurse

PRIMARY ROLE OBJECTIVE: 

Works with Clinic Supervisors in conjunction with Operations, Medical Providers and the Quality Improvement Team to ensure quality, comprehensive and coordinated care is delivered to patients in a PCMH/Team Based Care environment.

MAIN DUTIES & RESPONSIBILITIES: 

1. Assists care teams with identification of complex chronic diseases and conditions to ensure the patient population receives appropriate care. 
2. Coordinates care with the medical, behavioral health and dental teams and patients to assess needs, identify barriers and coordinate plans of care and communication among multiple providers. 
3. Coordinates transitions of care with patients, PCP and other service providers. 
4. Relays appropriate information between patient and care team by documenting in EHR. 
5. Monitors and processes voicemail, EHR messaging and email in a timely manner. 
6. Works to the level of their license to maximize their contribution to Team Based Care 
7. Acts as a resource to MAs to help them work to the level of their license 
8. Acts as a leader in integrated teams to establish and maintain a positive work environment and strengthen relationships between teams and departments. 
9. Functions as an RN Case Manager in direct patient care when needed for complex patients 
10. Assists with Case Management in a Team Based Care environment as needed under the direction of the PCP 
11. Supports and contributes to Quality Initiatives that advance the goals of Family Health Center. 
12. Follows the direction of the Infection Control Manager to uphold the highest standards of patient and staff safety. 
13. Participates in PDSA cycles, capturing pertinent information to maximize the effectiveness of Process Improvement 
14. Provides professional nursing care for FHC patients following established standards and practices and acting within the scope of the RN license. 
15. Interacts frequently with high risk patients regarding care plans, by phone and in the clinical setting. 
16. Acts as an educational resource for patients and staff. 
17. Develops and discusses patient self-management plans in conjunction with PCP. 
18. Follows up with patients to assess compliance and progress with identified goals. 
19. Provides decision support and encourages treatment adherence 
20. Assists in PCMH strategies to identify high risk patients based on diagnosis and other factors; use reports to access data on high risk patients; work with Clinic Supervisor & Operations Manager to help develop and implement processes to ensure high risk patients received appropriate care at FHC.  Triages patients to level of employee licensure: assess patients as needed and provide appropriate nursing care. 

1. Supports empanelment and helps to maintain accurate and appropriate Provider panels. 
2. Support Population Health to proactively improve the health of our community 
3. Participates in Team Based Care and Whole Person Care initiatives 

1. Works with QIP Leadership and the Clinic Nurse Supervisor to maintain compliance

WORK ENVIRONMENT Work is performed primarily in an ambulatory care setting, which may include working at sites other than their home clinic site. We may be required to work outside of the clinic when necessary to meet the needs of our community (such as at community events and at alternative care sites for infection control purposes).

 FHC strives to take every measure to ensure privacy and security. As part of our cyber security protocols, all employees must be able to participate in two-factor authentication.