RN Care Coordinator

Description

Summary

Chronic Care Management (CCM) - The RN Care Coordinator provides education and support to patients with chronic medical conditions.

Medication Assisted Treatment (MAT) - The RN Care Coordinator will assist clinicians with the delivery of primary health care to patients in accordance with Health Center policies and procedures, including providing nursing support for MAT services, including Suboxone and Integrated Care for Chronic Pain (ICCP).

Perinatal Nurse Educator - The RN Care Coordinator provides education and support to patients on pregnancy, childbirth and postpartum care.

The RN Care Coordinator works in partnership with the patient and medical staff, develops a care plan that is the right fit for the patient's condition(s) to ensure needed access to behavioral health and medical services and education/supports on self-management of medical condition(s).

On an as needed basis, supporting health services at Scenic Bluffs contracted schools as a substitute School Nurse.

Duties & Responsibilities

• Conduct comprehensive nursing assessment, including social, medical, mental health, substance use, and medication history
• Ability to practice trauma-informed care and apply de-escalation techniques
• Medication reconciliation, management, patient compliance, inventory, education in accordance with MAT Program
• Provide triage for the medical department including phone management and emergency patients.
• Assists providers in all aspects of the consultation, treatment, procedures, and follow-up care.
• Executing medical regimens and nursing interventions as appropriate for the setting and their competence.
• Patient health counseling and instruction, including meeting with families and caregivers.
• Provide RN only visits including blood pressure rechecks, vaccination only appointments, injections, etc.
• Assist in the development and updating of department policies and procedures.
• Organize and manage huddles, participate in panel management meetings, and contribute to other meetings as assigned.
• Maintain patient confidentiality in alignment with HIPAA.
• Complete accurate, legal, and ethical documentation in patient's electronic health record.
• Participate in and/or facilitate meetings and groups as requested including medical Quality Improvement
• Develops, in consultation with the patient and the medical staff and clinicians, a comprehensive, person-centered care self-management plan that includes all relevant information on MAT and/or chronic disease management, in addition to other medical, behavioral health, and dental relevant information.
• Identifies and/or develops education and supportive interventions to increase patients' skills and confidence in managing their health, including regular assessment of progress and setbacks, goal setting, and relapse prevention support.
• Educates patients and/or family members on controlled substances, including medication administration, storage, safety, responsibilities, program expectations and patient treatment agreements.
• Participates with regular staff meetings focused on coordinating care within an interdisciplinary team, providing the team updates on patients' progress in care.
• Participates in community vaccination/health promotion events.
• Engages patients in health and wellness related life skill development and activities.
• Performs job responsibilities consistent with standards for best practice nursing, including excellent communication with all providers to ensure the delivery of high-quality care.
• Follow-up with internal and external medical providers when barriers to care are identified.
• Identify community resources and promote access or referrals to them.
• Assist with primary care support as needed (i.e., patient rooming, lab draws, etc.)
• Occasionally supporting health services at Scenic Bluffs contracted schools as a substitute School Nurse.
• Act within scope of practice.
• Report to work as scheduled.
• Promote the mission, vision, and values of the organization in all interactions.
• Other duties as assigned.

Qualifications

The individual must respect the confidentiality of patient information while performing job duties and establish and maintain effective working relationships with patients, employees and public. The individual must also possess excellent understanding of prevailing standards of medical practice, and the ability to constructively participate in a clinical quality improvement. The position includes having to meet deadlines, deal effectively with time pressures and stress and write reports and correspondence. Intermediate math skills and legible handwriting is a must. Quality, accuracy, thoroughness, timeliness, and reliability of work performed are essential. The individual must have a valid driver's license, be insurable and provide own transportation.

Education and/or Experience

The individual must have earned a nursing degree from an accredited nursing school plus 3 years of progressively responsible nursing experience. Must also have at least 1 year of experience providing services to adults with substance use diagnoses from diverse economic and cultural backgrounds, as well as exceptional communication, interpersonal and organizational skills are required. Bi-lingual English/Spanish a plus but not a requirement. Current Healthcare Provider CPR certification is required.