Team Clinical Care Coordinator with Geriatric Emphasis (RN)
FLSA Non-exempt (Monday-Friday 8-5, no nights, no weekends)
Full-time, Benefits-eligible
Competitive Wage DOE + excellent benefits package
Position Summary
Under the general direction of the Lead Nurse, the Team Clinical Care Coordinator provides nursing services to members of the community who seek services at our clinic. This position will provide these services by working and collaborating with the entire healthcare team. This team includes providers, pharmacy staff, medical assistants, case management, behavioral health, all clerical, financial, and medical records staff, and all supervisors. This position will perform patient care duties in collaboration with the health care team (the medical provider is the team leader). This position provides skilled, comprehensive nursing care and implements health care plan for the patients and families to meet patient/family needs. The Team Clinical Care Coordinator will be assigned to lead the geriatric team including health education and screening through patient Medicare visits and care management for predominantly off-site medical visits. Maintains panel for certain providers for skilled nursing facilities, extended care facilities, and assisted living settings. This includes, understanding the pod panel, organization, communication, scheduling, timely EHR documentation, and following up on orders given to facilities.
Position Qualifications
- Must hold valid MT license for RN
- Minimum one-year experience preferred in a geriatric care model
- Demonstrated ability to problem solve
- As defined by Nursing Competencies has the following demonstrated abilities:
- Ability to work both independently and interdependently
- Excellent customer service skills
- Demonstrated effective communication skills
- Flexibility in working in a team setting
- Critical thinking and problem-solving skills
Essential Functions, Roles, and Responsibilities
A. Patient check in
· Identify patient by asking for name and date of birth (two identifiers)
· Take vital signs and document in electronic medical record (EMR)
· Review medication profile and document appropriately in EMR
· Review allergies
· Review and discuss patient’s tobacco, alcohol, and illicit drug use
· Review and document disease collaborative items as necessary
· Perform standing order or pre-ordered labs, weight checks, foot exam, and patient education as appropriate to each individual patient
· Assist patient in setting self-management goals using intake form as guide, document goals in Epic
· Complete, document, and review patient history in EMR
B. Performs nursing skills as necessary according to standard nursing procedure:
· Nursing staff should leverage daily huddles and communication to provide both administrative services and patient care
· Follows all safety policies and protocols while carrying out duties
· Draws blood samples for lab specimens, including order entry
· Performs IV therapy
· Prepares blood or other specimens for transport
· Performs EKGs, order entry
· Performs spirometry
· Performs CLIA waived lab testing, order entry, enter/edit results
C. Quality Control responsibilities
· Performs internal and external controls for CLIA waived lab testing as per standard procedure for each test
· Performs control testing and maintenance required for control testing on all lab equipment per standard procedure
· Performs testing/troubleshooting
D. Learning responsibilities/taking and giving direction
· Follows Montana Administrative Rules relating to Delegation of Tasks
· Willing to learn new lab/equipment/procedures as these items change with improvements in technology
· Takes personal responsibility to understand new procedures by following direction of trainer and completing self-learning packets as available
· Takes responsibility to request and attend appropriate CE offerings annually
E. Follow standard procedure for order entry and documenting in EMR:
· Immunizations are ordered in EMR, administered, and documented in EMR using accurate VFC allocation
· Maintain medication list, new and updates in EMR
· Maintain patient history in EMR
· Provider orders/instruction in progress note
· Lab results obtained by CLIA waived testing
· Pertinent patient information gained face to face, by phone or fax
· Referrals to outside agencies for testing or specialist care. Maintain tracking of referrals or collaborate with team members to ensure referral tracking completed
F. Infection Control—follows standard procedures
· Demonstrates proper hand washing 100% of the time
· Prepares and cleans exam room between patients
· Keeps work areas clean—all exam rooms, treatment room, lab room, nurse visit room, and desk area
· Empties sharps containers regularly—no container is ever in a room with contents above ‘the line’
G. Miscellaneous duties
· Stocks exam rooms each day if necessary
· Assists in the maintenance of inventory of medical supplies by using appropriate notification system for re-ordering medical supplies and pharmaceutical supplies
· Assures that all clinical areas are secure at the end of each shift by locking medication cabinets and securing any sensitive materials or equipment
· Asks for help from other staff as needed
· Uses courteous phone skills at all times
· Completes unusual occurrence/incident reports per standard procedure
· Arranges for coverage for lunch or meeting attendance—keeps other nurses informed of whereabouts during work time
· Request time off in a timely manner in accordance with policy
H. Continuum of care responsibilities
· Review medical tests received by clinic
o Checks in tests with date stamp and signature
o Brings urgent/emergent test results to provider immediately
· Notify patient of lab results and/or treatment plan/changes as instructed by provider—by phone or letter and documents in medical record
· Return patient phone calls during the shift they are received per internal policy and procedure
· Assist in electronic and paper medication refills, these should be completed according to internal policy and procedure
· Answer patients’ questions or direct them to appropriate resource
· Prioritize patient needs by gathering data and using that information to make an appropriate decision regarding care or referral of the patient
· Keep patients informed about status of appointment time if the provider is running behind, offers options if patient is anxious or unable to wait
· Assist with MyChart communication based on provider preference
· Using a team approach to complete in-box work performed between patient visits including patient forms, lab results, medication refills, prior authorization requests, and other paperwork that falls to physicians’ and providers’ oversight
· Keep medical provider focused on tasks: patient visit, electronic signing of encounters, signing off paper labs/test results, completing result notes for electronic lab results, hospital communications, nursing home follow up calls, meetings. Productivity goal: Medical team will see 16-20 pts in an 8-hour shift
I. Otherduties as assigned
Legal Concepts
- Practices within the scope of education, training, and personal capabilities
- Maintains strict and complete confidentiality
- Follows federal, state, and local legal guidelines; follows license criteria when licensure applies
- Maintains compliance
- Reports any evidence of abuse or neglect to provider or appropriate official
Supervision: None
Immediate Supervisor: Lead Nurse; in their absence, COO or designee
Physical demands/Working Conditions
General office/clinic conditions are pleasant; good, clean working conditions where accident and hazards are negligible. Some members of this class may be required to work regular or occasional weekends or other specified schedules based on the needs of the clinic. While performing the duties of this job, the employee is frequently required to be present; sit and talk or hear; use hands to finger, handle, or operate tools or controls; reach with the hands and arms; stand, walk, stoop, kneel, or bend. Employee must occasionally lift and/or move more than 25 pounds. Specific vision abilities require close vision and the ability to discern color and adjust focus.
OSHA Classification I: Normal work routine involves potential for mucous membrane or skin contact with blood and/or body fluids; use of appropriate protective measures is required.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.
SWMTCHC is an Equal Opportunity Employer
About Southwest Montana Community Health Center:Southwest Montana Community Health Center is a mission-driven, non-profit Federally Qualified Health Center (FQHC). FQHCs are community-based healthcare providers that receive funding from the Federal government to provide comprehensive primary care services in underserved areas. FQHCs provide care to all individuals, regardless of their ability to pay, and offer a sliding fee discount based on income. FQHCs must meet certain requirements to receive funding, such as providing services to medically underserved areas or populations, offering a comprehensive set of primary care services, and having a governing board that includes patients.Southwest Montana Community Health Center is a recognized National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH). PCMH designation is gained by meeting certain standards set by the NCQA. These standards include providing comprehensive, coordinated care, using evidence-based practices, and engaging patients in their care. Community health centers that receive PCMH designation are recognized for providing high-quality, patient-centered care that improves health outcomes and reduces costs. PCMH is our model of primary care that emphasizes care coordination, communication, and patient engagement to improve the quality of care and patient outcomes. The PCMH model encourages providers to work as a team to coordinate and manage care for patients, provide timely access to care, and use evidence-based practices to improve outcomes. The PCMH model also emphasizes the importance of patient engagement, providing patients with the tools and resources they need to take an active role in their own health care.We opened our doors in 1986 under the name Butte-Silver Bow Primary Healthcare Clinic Inc. Our main clinic is in Butte, Montana, and we have locations in Dillon and Anaconda, Montana. We offer medical, dental, behavioral health, care management, pharmacy, and clinical pharmacy services to everyone. We accept most insurances and private-pay clients, as well as uninsured or underinsured clients. Our passion is to ensure that healthcare remains accessible and affordable to everyone.Our clinics care for more than 13,000 patients annually and employs more than 150 people in our various locations.
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