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Form of workCommunity Health & Wellness Partners (CHWP) utilizes a team-based care model, sharing patient-care responsibilities among members of a team. Provide relevant nursing and support services in an ambulatory or care management setting. Provide care for patients with acute, chronic, and/or terminal illnesses. Participation includes interdisciplinary team, committees, program evaluations, research, and education.
Primary Tasks & Duties
- Maintains patient confidentiality.
- Participates in Patient-Centered Medical Home team meetings and quality improvement initiatives.
- Facilitates health and disease patient education, including leading group office visits.
- Supports patient self-management of disease and behavior modification interventions.
- Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
- Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.
- Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
- Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
- Facilitates patient medication management based upon standing orders and protocols.
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.
- Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
Qualifications & Requirements
- Graduate of accredited nursing program
- Associates Registered Nurse or Bachelor of Nursing.
- Five (5) years-experience as a Registered Nurse within a primary-care setting - Preferred.
Physical/Environment
- Occasional lifting of 40 – 50 lbs. and pushing of 5-20 lbs.
- Sitting, standing and walking approximately 80% of the time
- A medium to high level of manual dexterity, required.
- Bending and reaching approximately 20% of the time
- Availability to work in all CHWP locations
- Normal accessibility and mobility throughout the region, required.
- Normal overtime/extended work hours
Self-Care Benefits
- Monday - Friday (8 or 10 hour shifts)
- PTO
- 6 Paid Holidays
- Paid Birthday Off
- Paid Parental Leave
- 401K Match
- Weekends Off
- Medical, Dental & Vision
