DETAILS

SUMMARY:  Works within a multi-disciplinary team to ensure a patient centered approach to care including the relationship between medical, dental, optometry, community health workers/outreach, front office, and behavioral health providers.  Primary responsibility for care management include communication with the patients and the parents/guardians of minor patients; help identify patients who have health risk factors, especially for chronic diseases; communication specialists and other entities as appropriate; incorporate clinical quality measures into comprehensive patient care; and to provide high quality patient care by performing the assigned duties in a competent and professional manner.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following, with other duties assigned as appropriate:

Care Management

  • Reviews morning huddles for each care team and integrates care management into provider visit as necessary
  • Manage care transitions into long-term care, out of hospital (home care), etc.
  • Responsible for chronic disease patients as assigned in panel form. Primary responsibility will be to integrate care manager services into the patient visit to increase health outcomes. Also involves comprehensive chart reviews for these patients; monitor, evaluate, and adjust care plans/objectives based on effectiveness of interventions-development of self-management goals (preventative health care & chronic disease mgt).
  • Knowledge of Substance Use Disorder resources and have the ability to appropriately triage these patients
  • Involvement as assigned with Risk Management, Safety and Quality Improvement
  • Triage of patients according to triage protocol with appropriate documentation; assistance in emergent walk-ins
  • Establish patient opportunity visits with provider for complicated/abnormal encounters.
  • Assist in referral to CHW/Outreach assistance for community resources & support
  • Competency with vaccine identification and ability to identify age appropriate vaccines.
  • Competency with all Vaccines for Children (VFC) Program guidelines and vaccine storage and handling.
  • Must be competent in telephone etiquette, transferring calls, emergent intercom paging, and management of threatening phone calls.

Secondary Responsibilities

  • IV placement and monitoring, EKG’s, and other RN skills that require critical thinking and independent judgment
  • Assists provider’s Nurse/CMA with patient care in accordance to their scope of practice, including but not limited to:  patient rooming, setting up for procedures, assisting during exams as required, administering of medications, injections, and vaccines, lab specimen collection and performing venipuncture.
  • Able to perform both Encounter and Provider MSS duties according to job descriptions
  • Including simple nurse encounters: allergy injections, medication administration, immunizations, lab draws, hemoccult tests, blood pressure (stable), weight checks (stable), breath alcohol test, anticoagulation
  • Initiating prior authorizations, assisting with other requests from patients and other health care providers (insurance companies, homecare agencies, and other)
  • Lab Tracking per protocol
  • Fluency in the MCIR:  Registry, Vaccine Information Management, Reporting and Ordering processes, inventory and balancing
  • Ordering supplies and medications (or to designee MSS)
  • Inventory and restocking of supplies, equipment, medications, verifying receipt (or to designee MSS)
  • Verify and approve medication and supply ordering.
  • Complete vaccine supply ordering to allow for adequate patient supply
  • Monthly Clinical and Safety Checks (or to designee MSS)
  • Work as a Medical Support Staff (MSS) as necessary.

Documentation                                                                                                        

  • Maintain documentation of communications via the electronic medical record (EMR).
    • Appropriate documentation regarding patient visits, test results, phone notes, medication refills, patient education, procedures, referrals, diet, provider/patient response, etc.
  • Appropriate documentation of orders and diagnosis
  • Maintains proficiency in the use of the EMR
  • Completion of EMR down-time processes as appropriate
  • Able to utilize the electronic health record to review patient chart, update data, add information, run inquires and reports to acquire information needed for site management

Supplies/Equipment                                                                                    

  • Follows operating instructions for all equipment
  • Notification to direct supervisor when experiencing equipment malfunctions/breakdowns, supply shortages, etc.
  • Disinfection and sterilization of instruments and ensures MSS perform same process

Miscellaneous

  • Participates in continuing education services, meetings, mandatory in-services, and performance improvement/OSHA programs
  • Makes suggestions to improve TBCHS workflow and process
  • Maintains patient privacy and protects operations by keeping patient care information confidential in accordance with HIPAA
  • Serves and protects the health center by adhering to professional standards, policies and procedures, federal, state, and local requirements
  • Continuing Education – Updates job knowledge by participating in educational opportunities on a regular basis

EDUCATION and/or EXPERIENCE:   RN Associate’s degree (A. A.)

CERTIFICATES, LICENSES, REGISTRATIONS:  This position requires certification or licensure in the following categories:

  • BLS Required at hire.
  • Current valid RN License

PHYSICAL DEMANDS: Medium

TRAVEL: Travel between sites may be required