Nurse Care Coordinator Rn

Position Summary

The Nursing Care Coordinator serves as the leader of a team comprised of a Registered Nurse (RN), a Medical Assistant (MA) and Patient Services Representative (PSR) that support Providers to integrate each patient’s care across the life span. The Nursing Care Coordinator (NCC) will work with the Clinical Manager, Chief Operating Officer, Outreach Manager, BCHC Management Team and others to develop processes and systems that operationalize BCHC’s mission. The NCC actively supports all BCHC efforts to remain Federally Qualified Health Center (FQHC) and PCMH designation by providing quality care regardless of economic status

Job Description

• Serves as the primary liaison between BCHC patients empaneled to a BCHC provider. Coordinate with each new patient to establish and maintain relationship.
• Ensures continuity of care through ongoing communication with each patient on the provider’s panel.
• Collaborates with the patient/family to develop an individualized care plan, including treatment goals that are reviewed and updated at each relevant visit.
• Assesses and addresses barriers when patient has not met treatment goals.
• Develops, implements and documents tracking activities associated with Patient Centered Medical Home (PCMH)
• In conjunction with other care team members, tracks all referrals and all other high priority issues identified by the PCP in accordance with the BCHC Referral Tracking Policy and Procedure.
• In conjunction with the Primary Care Provider (PCP) actively promote patient and family engagement
• Respects the centrality of the patient/family as core members of the health care team.
• Examines how the safety, quality and cost effectiveness of health care can be improved through the active involvement of patients and families.
• Examines common barriers to active involvement of patients in their own health care processes and assist to reduce barriers when possible through the use of the entire care team
• Utilizes strategies to empower patients or families in all aspects of the health care process.
• Develops and implements strategies to collaborate with patients, providers, families and caregivers to enhance continuity of care and effective utilization of health care resources.
• Defines and maintains coordinated care strategies between BCHC and other inpatient and outpatient health care providers aimed at improving patient referrals and follow-up.
• Assist referral coordinator with prior authorizations when needed. Track and monitor and adjust provider’s patients on long-term anticoagulation therapy (such as Coumadin) in accordance with required protocols/standing orders.
• Manages prescriptions and refill requests for designated patients.
• Identifies appropriate resources within BCHC and the community to support patient self-management.
• Develops and documents self-management plans and goals for patients and families.
• Provides self-management tools to review record self-care results.
• Encourages participation in BCHC-based education and support programs.
• Refers patient to community based support and education programs as appropriate.
• Serves as the leader of the Clinical Support Team to assist the provider
• As part of the leadership role on the clinical team, assist and improve BCHC’s care coordination model.
• Facilitates Morning Huddles, providing direction and assistance to other members of the Clinical Support Team as needed to improve efficiency and productivity of the meetings.
• Coordinates with community resources to provide patient education, outreach, and preventative health programs.
• In collaboration with clinical management, providers and peers, develops and implements productivity strategies to make day-to-day practice activities and patient flow more efficient and standardize processes and protocols across BCHC.
• Develops and provides patient education.
• Provides education and clinical support for unlicensed personnel.
• Provides clinical support in caring directly for patients and assisting in monitoring medical conditions.
• Utilizes standing orders and protocols to coordinate support to assigned providers on a daily basis.
• Performs patient assessments and documents findings.
• Administers injectable medications and vaccines per provider’s orders.
• Acquires pertinent patient history from the patient and/or significant interim items prior to patient being examined by healthcare provider.
• Performs as Triage Nurse as assigned.
• Answer all sick line calls.
• Evaluates walk in patients and determines appropriate disposition.
• Completes Nurse Visits.
• Enters all necessary documentation, ensuring accuracy and completeness, required for billing, quality and safety initiatives.
• Monitor and prioritize the inboxes for routine and care coordination needs.
• Prepares paperwork for provider review and signature.
• Schedules hospital and emergency room follow up patients.
• Coordinates obstetrical care and ongoing collaboration with OB team.
• Completes physical exam and other forms for provider signature.
• Other responsibilities that become incorporated into the BCHC Care Coordination Model.
• Participates in activities aimed at increasing the visibility of BCHC in community-wide health care initiatives.
• Serves as facility point person/subject matter expert (SME) for external agencies (PA VFC program, PA Infectious Disease reporting, etc.).
• Performs CLIA waived testing after demonstrating competency on each test the facility has a waiver for.
• Other duties as requested.

Job Type: Full-time

Pay: $75,000.00 - $85,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Nursing: 1 year (Required)

License/Certification:

• RN (Required)

Willingness to travel:

• 25% (Preferred)

Work Location: In person