What are the responsibilities and job description for the Registered Nurse position at Miles River Primary Care?
Join our practice in an RN role that functions beyond traditional triage, emphasizing chronic disease management, quality oversight, clinical staff leadership, and value-based care within an adult primary care practice.
Chronic Disease Case Management
- Manage patient populations with chronic conditions including:
- Diabetes
- Hypertension
- Hyperlipidemia
- Heart failure
- COPD and asthma
- Chronic kidney disease
- Obesity
- Depression and anxiety
- Develop individualized care plans in collaboration with providers.
- Monitor disease-specific quality metrics and clinical outcomes.
- Perform medication adherence assessments and reconciliation.
- Coordinate specialty care and community resources.
- Conduct transitional care and post-hospital follow-up calls.
- Identify high-risk patients requiring intensified care management.
Patient Education
- Provide education regarding:
- Disease management
- Medication administration and adherence
- Lifestyle modifications
- Nutrition and exercise
- Smoking cessation
- Preventive screenings
- Vaccinations
- Self-monitoring techniques
- Reinforce provider treatment plans.
- Utilize motivational interviewing techniques to improve patient engagement.
- Document patient education and understanding.
Quality Improvement & Population Health
- Monitor practice quality measures, including Medicare, commercial payer, and value-based care metrics.
- Identify care gaps and coordinate outreach for preventive services.
- Assist with annual wellness visits and preventive care initiatives.
- Participate in quality improvement projects.
- Support compliance with Patient-Centered Medical Home (PCMH) standards.
- Assist with HEDIS, MIPS, and other value-based reporting initiatives.
- Monitor immunization and preventive screening compliance.
- Participate in clinical audits and performance improvement activities.
Clinical Staff Oversight
- Provide clinical guidance and mentorship to Medical Assistants, LPNs, and other clinical support staff.
- Monitor competency and adherence to clinical protocols.
- Assist with orientation and ongoing training of new employees.
- Ensure appropriate delegation of clinical duties.
- Promote teamwork and effective communication among staff.
- Assist leadership in maintaining regulatory compliance.
Care Coordination
- Coordinate care among primary care providers, specialists, hospitals, home health agencies, and community organizations.
- Participate in multidisciplinary care planning.
- Monitor referrals and follow-up appointments.
- Assist patients with navigating healthcare resources.
Compliance & Documentation
- Maintain accurate, timely documentation in the electronic health record.
- Ensure compliance with HIPAA, OSHA, CLIA, CMS, and state nursing regulations.
- Maintain infection prevention and safety standards.
- Participate in regulatory inspections and accreditation activities.
Qualifications
- Current Registered Nurse (RN) license in the applicable state.
- Minimum of 2 years of clinical nursing experience; primary care or ambulatory care experience preferred.
- Experience with chronic disease management, quality improvement, and population health preferred.
- Proficiency with electronic health records (EHR).
Knowledge, Skills, and Abilities
- Strong assessment and clinical decision-making skills.
- Knowledge of evidence-based primary care guidelines.
- Excellent patient education and communication skills.
- Ability to prioritize multiple responsibilities in a fast-paced environment.
- Leadership and supervisory skills.
- Knowledge of value-based care and quality reporting programs.
- Strong organizational and problem-solving abilities.
- Commitment to patient-centered, team-based care.
Pay: From $27.00 per hour
Benefits:
- Health insurance
- Paid time off
Work Location: In person
Salary : $27