Nurse Case Manager - Cardiac Rehabilitation (Ornish Lifestyle Medicine)

JOB DESCRIPTION

TITLE: Registered Nurse

SUPERVISOR: Ornish Director

FLSA CLASS: Exempt FTE: 1.0

POSITION DESCRIPTION

Under the supervision of the Medical Director, the Registered Nurse assists practitioners in providing primary care in accordance with licensure. The RN is also responsible for actively coordinating and monitoring all clinical aspects of the Ornish Program intervention under the supervision of the Ornish
Director. The RN ensures the appropriate selection of participants, is physically present to monitor patient safety during the 4-hour session and communicates health status updates with referring physicians as needed.
Actively participates in the development of the transdisciplinary treatment plan to ensure the quality and clinical effectiveness of the Program, and the safety of each participant.

ESSENTIAL DUTIES AND FUNCTIONS

General Nursing

• Serves as a patient advocate, resource and contact person for patients.
• Provides care coordination services including coordinating access to in-house and community resources and coordinating transition between points of care;
• Provides case management to ensure patient compliance with treatment/care plans.
• Manages all laboratory/diagnostic tracking systems including the Electronic Medical Record to monitor, identify and recall patients with out of range and/or required laboratory and diagnostic testing.
• Triages patients who call or present with urgent medical needs, and handles all incoming calls related to lab results, pharmacy refill requests, and medical questions.
• Provides basic education information and self-management goal support to patients and family, focusing on self-care appropriate to their age and identified learning considerations and needs.
• Administers medications and intravenous solutions.
• Greets and escorts patients to appropriate clinical areas.
• Obtains information from patients vital for successful a clinical visit which may include: patient’s vital signs, weight, medical history, etc.
• Assist patients in obtaining assistance with specific programs including but not limited to patient assistance programs for insurance, medications and treatment.
• Assists care team to ensure equipment, supplies and medications are ordered and stocked.
• Assists in screening calls for practitioner and follows-up on all necessary phone, electronic or fax messages.
• Assists team members with all patient support and educational groups or sessions.
• Assists or performs all necessary preventive screening, CLIA waived labs, immunizations or other treatments as ordered by physician.

Ornish Program Case Management

• Coordinates the potential participant through the screening and intake process.
• Determines the eligibility of potential participants with the oversight of the Medical Director.
• Responsible for completion of the electronic platform, Diaweb, and the data collection required throughout the 72-hour program and at one year.
• Performs a comprehensive health assessment at baseline on all participants. Performs an assessment on every participant before each intervention session to ensure safe participation.
• Accesses element specialists and resources, as needed, during the screening and intake process.
• Completes requests for reimbursement procedures as outlined by contracted and non- contracted payers.
• The RN assesses participant’s clinical response to the Interdisciplinary treatment plan and directs communication to the appropriate specialist, Medical Director and/or referring/primary physician. Provides leadership for weekly case conferences and participates as a member of the transdisciplinary team to ensure the quality and clinical effectiveness of the program.
• Performs regular, ongoing health assessment on each participant, consults the multidisciplinary delivery team as appropriate, and updates the interdisciplinary treatment plan as needed.
• Provides clinical updates to the Medical Director, referring/primary physician,

Program Director(s) and to all members of the team.

• Participates in the program’s interactive lecture series and in the ongoing education of participants as needed.

Other Duties

• Attains electronic health record superuser status, is available to the team for questions regarding the electronic health record and monitors ongoing documentation of each participant’s health status in response to the intervention throughout the Program.
• Coordinates the interdisciplinary development, implementation, and evaluation of the interdisciplinary treatment plan for each participant.
• Coordinates and leads weekly team meetings/care conferences and participates in the monitoring and documentation of the participant’s response to the interdisciplinary treatment plan throughout the intervention.
• Immediately available at all times to the participants and the delivery team during all 4- hour Program sessions.
• Develops, performs, and evaluates a multidisciplinary emergency procedure/protocol to assure participant safety in all aspects of the Program.
• Assists the Exercise Physiologist with the monitoring of the exercise element of the program.
• Assists the Stress Management Specialist in the stress management sessions as needed.
• Assists the Group Support Facilitator during the Group Support element sessions as needed.
• Delivers educational lectures as needed.
• Coordinates and documents the participant’s access to and follow-up of resources and interventions recommended by the team.
• Complies with HIPAA privacy and patient confidentiality policies and procedures.
• Facilitates and participates in the care transition plan for each participant who completes and/or does not complete the program.
• Attends and participates in mandatory monthly element specialist calls hosted by the

Ornish National Training Center.

• Assists the Program Director with efforts to actively promote the program to prospective participants and health care professionals as needed.
• Facilitates a high level of participant satisfaction.
• Personally models the program by embodying its principles, philosophy and practices.
• Provides support to Ornish Alumni Community as needed.
• Attends and participates in weekly team meetings/case conferences.
• Participates in the development of the interdisciplinary treatment plan for each participant.
• Participates in the monitoring, documentation, and communication of the participant’s response to the interdisciplinary treatment plan throughout the program.
• Personally models the program by embodying its principles, philosophy and practices.
• Attend regular staff meetings, conferences, training sessions, and other meetings.
• Follows policies and code of ethics outlined in Employee Handbook.
• Maintains professionalism within the organization and outside the clinic during all working hours and when representing the organization.

Physical Demands
Frequent sitting at desk for office work. Driving of automobile for outside appointments and meetings. Occasional climbing stairs, step stools, occasional stooping, kneeling, crouching, crawling, reaching, and turning. Continuous use of corrected vision, depth perception, wide field vision, and color vision. Continuous use of olfactory, auditory, and tactile senses. Occasional pushing/pulling and lifting.

Communication Demands
Frequent talking to patients providing education and guidance. Occasional talking to public regarding physicians, community agencies, and professionals. Talking on telephone, training/giving instructions, receiving instructions, writing, and composing written language. Ability to work with diverse populations.

DECISION MAKING

Exercises independent decisions on practices related to exercise and the physiology drawing on years of experience and extensive training or education.

WORKING CONDITIONS

Indoor in air-conditioned environment. Occasionally required to be outdoors for travel, and can be exposed to variable weather conditions. Occasional inter-island travel by commercial air carrier or boat. Occasional exposure to noise, moisture, noxious odors, and gases. Occasional exposure to dust, dirt, cold, and biological and chemical agents.

Work Hours
8-12 hour work days with variable hours depending on patient and program needs. Overtime may be required. Rotation onto weekends and evening shifts as necessary.

Equipment
Frequent use of telephone system and office equipment, i.e. typewriter, computer, printer, FAX machine, copier, and general office supplies. Occasional use of wheelchair, gurney and other assistive devices for patient transfers in the clinic. Frequent use of telemetry equipment and exercise equipment.

Travel
Must be able to travel to satellites and other locations as deemed necessary to perform job duties.

QUALIFICATIONS

Education/Certification

• Bachelor of Science in Nursing
• Active Registered Nurse license in good standing with the State of Hawaii
• Minimum two years of clinical experience in adult cardiovascular nursing and/or Cardiac Rehabilitation
• Current certification in Advanced Cardiac Life Support (ACLS).

Skills/ Experience

• Computer literacy
• Exemplary organizational and time management skills
• Coaching and/or motivational interviewing education or experience
• Diabetes education or experience
• Excellent public speaking skills and knowledge of adult education and coaching principles
• Excellent interpersonal communication skills with sensitivity to participant needs
• Desire and willingness to collaborate as a member of a high-functioning transdisciplinary team that supports personal transformation.

Other

Willingness to drive to various sites; current State of Hawaii Driver’s License required; current automobile insurance requirement on car being driven; annual TB test required and hepatitis B series recommended.

The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory, or all duties, responsibilities, and qualifications of employees assigned to this job. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform essential functions of this position.

10/26/2023

EMPLOYEE: DATE:

SUPERVISOR: DATE:

EXECUTIVE DIRECTOR: DATE:

Job Type: Part-time

Pay: $44.00 - $46.00 per hour

Expected hours: 20 per week

Benefits:

• 401(k)

Medical specialties:

• Primary Care

Physical setting:

• Clinic
• Inpatient

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Application Question(s):

• Must be on the Island of Maui

Work Location: In person