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Our Culture: Why work with us?
Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.
Who We Are :
Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.
OCHS now cares for more than 18,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it, and validating that staff are working at the top of their licensures, are foundations of this model.
Our Core Competencies:
At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.
A day in the life of this role:
Outer Cape Health Center (OCHS) is a patient-centered community center and every role requires functioning effectively using a team-based approach to provide and to facilitate quality care to our patient population in a dignified and positive manner. Responsible for high risk, patient population health care management and coordination as part of OCHS overall medical management and quality strategy. To accomplish this, the RN Case Manager will support the patient in becoming an active participant in his or her own health care. Works closely with OCHS provider teams, the community navigation team, and the ACO to assist in effectively managing the care of patients and meeting key performance indicators. Nurse Case Manager will be a highly organized and self-directed. The following statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities and skills required of this position.
Summary of duties:
- Provides case management to patients identified needing external resources to provide patient continuity of care across all age group/specialties.
- Facilitates education, resource management for patient.
- Monitors for compliance with said treatment plan
- Liaisons between patient, providers, and community resources.
- Assesses patients, and using established medical criteria develops a rational plan of care for ensuring the quality of care while improving the efficacy of care. This includes reviewing medications, referrals to other programs and services, ancillary service utilization, hospitalizations, ED visits and extended care admissions. Reaches out to patients who are due for PCP evaluation to help facilitate evaluation and treatment.
- Documents the plan of care and monitors patients on a basis determined by patient need. Evaluates the plan to ensure that it is reasonable, effective and outcome oriented.
- Provides post-discharge calls to patients and ensures discharge instructions are understood, performs med reconciliation, ensures appointments are scheduled, etc.
- Works closely with other OCHS resources to support patient.
- Responsible for working nursing in baskets in timely and efficient manner
- Coordinates care for patient/family
- Critical thinking and problem solving to determine the best care plan for each patient
What we need from you:
- Unrestricted Active Registered Nursing License
- Bachelor's degree in Nursing preferred
- Certification in Case Management preferred
- 3-5 years related work experience required
- 3-5 years' experience with strong medical-surgical clinical background
- American Heart Association - Basic Life Support Certificate
- Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access
- Homecare and or case management experience preferred
- Mature, energetic self-starter, adaptable - looking for a confident individual with strong clinical skills who will be able to participate in role development and who will be able to adapt to role changes as they evolve
AAP/EEO Statement Outer Cape Health Services is committed to a firm policy in favor of equal employment opportunity and will abide by all applicable state and federal regulations by not discriminating against any applicant or employee on the basis of race, religion, color, creed, sex, age, national origin, citizenship status, marital status, sexual orientation, gender identity and expression, disability or veteran status. Our commitment to equal employment opportunities shall include employment, upgrading, promotion, demotion, transfer, leaves or other absences from work, layoff, compensation and benefits, selection for training or other education, professional opportunities and conflict resolution.
It is also the policy of OCHS to take affirmative action to employ and to advance in employment, all persons regardless of their status as woman, minority or individuals with disabilities or protected veterans, and to base all employment decisions only on valid job requirements.
Please inform us of any necessary accommodations required during the application process and/or at any time during employment.
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