Position: Resource Nurse, RN/LPN/CMA
Department: Physician Clinics
Works collaboratively with providers, staff, and other healthcare professionals to provide comprehensive care management and care coordination across the health care continuum in order to improve outcomes and lower the cost of care. Assists provider and clinical staff with clerical/clinical functions for patients requiring chronic disease coordination. Acts as an integral member of the healthcare team who works to ensure safety, best practice, and high-quality standards of care are maintained. Works to ensure members are able to navigate through the healthcare continuum by improving the coordination of care and member/family experience. Coordinates a wide range of self-management support services as well as a wide range of community-based and health care support services for members. Works with providers, staff, and other resources to address specific quality improvement initiatives. Performs all functions of clinic nurse on a regular basis.
Graduation from an accredited program of nursing with current licensure as a Registered Nurse in the State of Iowa is mandatory. Bachelor’s degree in nursing or a related field preferred. Prior experience in nursing, physician clinic settings, care coordination, or similar preferred. Ability to adapt to flexible work schedule and frequent interruptions. Ability to prioritize to meet deadlines on daily work and special projects. Must be able to work independently with minimal supervision. Effective oral and written communication skills, excellent interpersonal skills. Must exhibit a high degree of responsibility for confidential matters.
- Provides care coordination and health coach services to all patients.
- Assists and coordinates various functionality and utilization of disease registry database including data entry; assuring database is kept up to date; identifying patients overdue for visits, labs, or referrals; identifying patients not meeting clinic goals; and creating patient, provider on clinic level quality performance reports.
- Proactively contacts patients to arrange follow-up on process or outcome goals.
- Conducts pre-visit chart review to identify all needed preventive health maintenance, immunizations, and chronic disease interventions. Needed interventions will be communicated to providers or ordered by protocol.
- Performs individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
- Communicates a plan for healthcare needs between physician/office visits.
- Coordinates needed patient education regarding specific health care skills and general disease concepts.
- Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME and other potentially preventable services
- Educate patients about their condition and assists with goal setting and plans for behavior change.
- Acts as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital discharge. Facilitates a timely linked appointment for high risk patients with both the care provider and the health coach.
- Promotes coordination with consulting physicians (specialists) and other health care providers, including referral management to other physicians, transfer of clinically relevant information needed by the healthcare team.
- Assists in the identification of “at risk” and “high risk” member populations needing care coordination.
- Identifies potential barriers related to a patient’s ability to effective self-manage and works with patients (and caregiver) to resolve identified issues. Works with member and families to optimize self-management skills through effective referral and coordination to appropriate community resources.
- Assist with clinic QI activities.
- Conducts pre-visit chart review of patients.
- Performs all functions of clinic nurse on a regular basis.
Additional Duties and Responsibilities:
- Understands and complies with the requirements of the ACMH Compliance Program, including, but not limited to the Code of Conduct, the Compliance Policy, all organization-wide policies for compliance, and compliance plans affecting specific duties and responsibilities.
- Participates in all education and training programs regarding compliance as required by ACMH and as requested by supervisor.