Under the general direction of the Chief Medical Officer performs overall Registered Nursing care, including triage for drop-in and telephoning patients, immunization administration and oversight; oversees all aspects of operating an assigned site from supervising clinical and support staff to monitoring patient care; acts as facility contact person and troubleshooter regarding service issues.
- Provides nursing services including: medications and injections to patients as directed by the providers; immunizations; referrals to other providers and community health resources; and health instruction to patients or following examinations
- Monitors patient flow and, in the case of patient overflow, assists medical staff in preparation of examination rooms, preparation of patients for exam, and taking of vital signs of patients. Performs other routine procedures (i.e., weighing and measuring), as necessary.
- Supervises all nursing functions at the health center site assigned including immediate supervision of other nurses and clinical staff to assure conformance with established standards and procedural requirements.
- Oversees and assists the Medical Assistants to adequately supply routine medical supplies; reorders supplies through established purchasing procedures.
- Maintains updated file of referrals and provides referral information to Medical Director.
- Triage all medical calls and drop-in patients for the health center.
- Participates in general and medical staff meetings as required.
- Oversees Medical Assistants and Patient Service Representatives in preparation of staff schedules and assures that adequate coverage is provided to providers and health center sessions.
- Assist the Medical Director, Nurse Practitioner, and/or Executive Director on matters relating to nursing practices and participates in development of policies and protocols for patient care.
- Performs all duties and services in full compliance with all regulatory requirements.
- Performs other related duties as may be assigned by the Medical Director, Nurse Practitioner, and/or Executive Director.
Primary objectives of the position:
- Coordination of care for patients experiencing a transition to or from care facilities and/or providers.
- Coordination of care with specialists and other health care providers (referrals, testing, procedures, etc.).
- Practice-based care management for patients at highest risk for health deterioration, sentinel events, and/or poor outcomes.
- Decrease in the readmissions, emergency visits, admissions, and decreased length of stay in necessary admissions.
- Improvement in disease-related outcome measures.
- Understanding the complexities of integrating services.
- Developing/managing tracking and documentation systems for patients admitted to and discharged from the hospital, patients seen in the emergency room (ER), and patients transitioning from or to any other health care facility.
- Assuring that care is patient-centered and that the patient/family are informed about the plan of care and are involved in decision-making about that care.
- Identifying and managing the patient’s primary driver (reason that caused the hospitalization or ER visit).
- Comprehensively assessing patient’s physical, mental, and psychosocial needs.
- Triaging high risk patients to identify the highest risk patients based severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly-pharmacy, and health care utilization trends.
- Maintaining a registry of highest risk patients with documented completion of measures and interventions.
- Developing care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.
- Utilizing behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease.
- Assisting patients in problem-solving issues related to health care system, financial and psychosocial barriers.
- Ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of care manager interventions.
- Coordinating care with other care managers across the continuum of care and payers.
- Communicating/affirming patient needs, plan of care, and changes in status with the PCP, team and the patient/family.
- Developing/managing care coordination systems that support referral, test completion and report receipt, and an integrated plan of care with specialists and other providers across the continuum.
- Training of office staff in the coordination of care with specialists and other providers across the continuum.
- Full Unrestricted Registered Nursing License in the Commonwealth of Pennsylvania
- Two years in a supervisory role in a community health center or hospital required
- Experience in case management, disease management, home health care nursing, hospital nursing or intensive outpatient education and self-management support preferred
Current CPR certification
- This position requires compliance with Health Center’s written standards, including its Standards of Conduct and policies and procedures (“Written Standards”). Such compliance will be an element considered as part of the employee’s regular performance evaluation.
- Failure to comply with Health Center’s Written Standards, which may include the failure to report any conduct or event that potentially violates legal or compliance requirements or Health Center’s Written Standards, will be met by the enforcement of disciplinary action, up to and including possible termination, in accordance with Health Center’s Compliance Program Policy and Procedure: Addressing Instances of Non-Compliance Through Appropriate Disciplinary Actions.
External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case-by-case basis.