The nurse supports the mission of PrimeCare Community Health to promote wellness and provide accessible, compassionate, and culturally respectful health care. Is responsible for coordinating and providing care management to empaneled patients with identified complex care needs. Addresses patient needs by providing care management and other resources. Provides guidance and leadership to other team members, including Case Managers, Medical Assistants, Referral Coordinators, Medical Records, and Providers. Is also responsible for being able to fulfill the duties of the Clinical Operations Nurse.
Duties and Responsibilities
1. Identification and tracking of medium- and high-risk patients with care coordination and oversight via:
a. Comprehensive risk assessments.
b. Integrated patient care plans focusing on disease self-management.
c. Ongoing clinical assessment, monitoring and contact.
d. Assessment of behavioral health needs, working with Behavioral Health Care Coordinators in identifying community or internal/external agencies, resources and programs.
2. Promote clear communication amongst team members regarding patient care plans and progress.
a. Works closely with other team members around specific care management tasks and responsibilities.
b. Communicate clearly and collaborate closely with primary care providers.
c. Lead the multidisciplinary complex care management meetings.
3. Support in maintaining patient health and prevention of secondary disease complications by providing education, counseling and support about healthy lifestyle changes and specific disease management topics.
4. Collaborate and participate in the selection, development and maintenance of patient education materials.
5. Participate in care transitions for medium and high risk patients, particularly from acute inpatient and emergency department settings, back into the medical home.
6. Utilize standing orders and clinical orders for preventative and chronic disease management within scope of clinical practice.
7. Preform medication review, reconciliation, education and coordination.
8. Participate in care team huddles and meetings.
9. Participate in the evaluation of the care management programs.
10. Make home visits if indicated.
11. Handle protected health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA).
12. Participate in PrimeCare’s quality processes and activities as indicated.
13. Maintain current knowledge of regulatory agency requirements of compliance and ensures that those standards are practice in the clinic.
14. Other duties of assigned.
Required Knowledge, Experience, or Licensure/Registration
1. RN-Active State of Illinois License Strongly Preferred or LPN
2. Bachelor’s Degree-in nursing preferred
3. At least 1 year of nursing total experience preferred
4. Prior experience in care management preferred
This job specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.
Chicago, Illinois , 60641
PrimeCare Community Health
Feb 27th, 2018