About Job

Overview:

The RN/Care Coordinator works in collaboration and continuous partnership with patients and their family/caregiver(s), hospitals, specialty providers and staff, and community resources in a team approach. The RN also provides supportive functions to NHS providers,

Essential Functions & Responsibilities:

General Nursing:

· Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources

· Handles incoming triage calls: (LPN under the supervision of RN and Medical Director)

o Provides appropriate patient education regarding medical condition

o Provides medication instructions

o Supports providers by following up with patients regarding their lab/imaging results as guided by the provider

o Documents telephone discussions in the patient’s electronic medical record (EMR)

· Handles incoming Nursing Home Orders

· Handles incoming pharmacy questions, clarifications and prior authorizations

· Calls patients with medication changes, directions and education, as ordered by providers

· Provides nursing support, when needed, to the RNs and NHS providers

· Utilizes the Patient Portal to communicate with patients

· Sees patients on daily nurse schedule:

o Responds to the needs of walk-in patients

o Assists providers and clinic RNs as needed

o Provides (RN) or reinforces (LPN) education on medical condition, e.g., asthma, diabetes, family planning

o Reads and documents PPD results

· Provides refill requests that come through the EMR, phone or fax

· Reconciles medications

· Maintains an emergency box of medications

· Oversees the application/enrollment and tracking process for patients in indigent medication programs

· Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency (RN only)

· Provides community-based nursing care as established by the organization, as requested

Care Coordination/Case Management Support:

· Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:

o Assists with the identification of “high risk” patients (those with chronic illness and/or special health care needs)

o Contacts patients to enroll them into HCH and documents patient’s acceptance or declination, to populate the registry

o Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care and educates patients on when to utilize the ER

o Reviews FUHN/ID Stratification patient’s EMR to see what patients may need; refers to specialty providers and to help with medication reconciliation

· Works with patients to plan and monitor care:

o Assesses patient’s unmet health and social needs

o Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

o Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed

o Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire

· Facilitates patient access to appropriate medical and specialty providers

· Educates patient and family/caregiver(s) about relevant community resources

· Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals

· Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider

· In collaboration with the primary care provider, assigns the appropriate tiering level based on required criteria for HCH patients

· Advocates for the participant in understanding needs surrounding transportation, shelter, child care and safety. Refers participant to behavioral health services if warranted

· Keeps EMR care plans updated for easy access by HCH Team

· Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox messaging and/or team huddles to update and advance care coordination within the Team

· Utilizes all available tools to deliver education, instruction, care coordination and training, including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies & procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease management brochures; disease management participant tracking records (Diabetes glucose records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific educational handouts; services offered by NHS

Core Requirements:

· Works collaboratively and respectfully with staff and others—individually and as part of a team—to achieve optimal efficiency, outcomes and morale

· Interacts in a culturally competent manner with individuals and groups from diverse backgrounds, including but not limited to: socio-economics, race and ethnicity, nationality and religion, both in-clinic and in the community

· Maintains excellent and punctual attendance

· Attends and actively participates in staff and departmental meetings

· Attends agency functions and meetings as relevant or required

· Works at any or all NHS clinics, as needed

· Uses computer daily including e-mail, word documents, spreadsheets, patient management system, electronic health record, and patient portal, as needed to carry out essential job functions

· Maintains any required licensure/certification

· Demonstrates commitment to agency mission and goals

· Abides by corporate compliance program, HIPAA regulations and other agency policies and procedures

· Participates daily in pre-visit planning and huddles (RN/LPN, Provider, Medical Assistant, Front Desk)

· Plans, organizes, and multitasks

· Speaks, understands, reads and writes English sufficiently to carry out all essential duties

· Performs other duties as assigned

Qualifications:

· Graduation from an accredited nursing program

· Current Minnesota RN/LPN license/certification

· Minimum one year experience in a primary care setting preferred

· Patient education experience