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Chronic Care Management Nurse
2 months ago
WE ARE HIRING....
At Comprehensive Community Action, our mission is to empower individuals and communities facing challenges due to poverty and social barriers through advocacy, education, and access to high-quality health and human services.
Position: Chronic Care Management Nurse
ROLE AND RESPONSIBILITIES:
The Chronic Care Management Nurse will collaborate with a multidisciplinary healthcare team within a community health clinic environment. This role is integral to a program focused on delivering healthcare through innovative methods within the patient-centered medical home model. The Nurse will be tasked with conducting thorough screenings, assessments, care coordination, disease education, and self-management support for patients with chronic health issues, including but not limited to coronary artery disease and depression.
KEY DUTIES INCLUDE:
- Operating under the guidance of the Nursing Director.
- Conducting initial patient evaluations, which encompass comprehensive medical, psychosocial, and functional assessments, including home visits when necessary.
- Providing in-depth education regarding patients' specific chronic conditions, covering aspects such as pathology, symptoms, complications, and treatment medications.
- Ensuring that preventive screening tests are current.
- Developing care management plans, interventions, and treatment objectives, including self-management goals and follow-up schedules.
- Encouraging adherence to chronic care plans.
- Coordinating care and liaising with various healthcare providers, both within and outside the practice.
- Analyzing test results and monitoring patient outcomes.
- Addressing patient compliance challenges.
- Facilitating one-on-one patient interactions.
- Organizing group consultations.
- Utilizing EMR and chronic disease registry data to prioritize patient follow-ups.
- Identifying and leveraging cultural and community resources.
- Preparing quarterly reports detailing service volume, patient distribution by plan, and types of services rendered.
- Maintaining effective communication regarding patient status with physicians and office personnel.
- Acting as a liaison to hospitals, long-term care facilities, and specialists.
- Participating in mandatory training and collaborative sessions, including learning workshops and practice team meetings.
- Training staff in motivational interviewing techniques.
- Coordinating with insurance companies and external agencies' Case and Disease Management teams as necessary.
QUALIFICATIONS REQUIRED:
- Licensed Registered Nurse from an accredited institution.
- Three to five years of experience in community health, public health, chronic disease management, or case management is preferred.
- Current BLS certification.
- Experience in patient care coordination and disease management education is advantageous.
- Ability to perform quality work within deadlines, with or without supervision.
- Fostering a positive work environment by sharing best practices and serving as a mentor.
- Representing the organization positively to all patients and external clients.
WORK ENVIRONMENT AND PHYSICAL DEMANDS:
This position requires frequent use of phones, writing, typing, and performing vital signs, along with verbal communication. Duties are typically carried out in a healthcare office setting, with mobility required for meetings and presentations. Travel to various locations may be necessary, usually by car, and regular lifting of up to 25 pounds is expected. A good attendance record is essential, and reasonable accommodations may be made for individuals with disabilities.
SCHEDULE REQUIREMENTS:
- This is a full-time position as specified by the program director.
- Occasional unscheduled overtime may be necessary.
- Flexibility to work at any Family Health Services location as directed by the Director of Quality Improvement and Compliance.
COMMUNICATION SKILLS:
- Daily interpretation of technical medical terminology.
- Utilizing various communication methods with patients, including interpreters, individual counseling, group discussions, written materials, and visual aids.
- Understanding the cultural, social, and economic characteristics of the patient population served.
- Effectively communicating with staff and providers in a tactful manner.
CONFIDENTIALITY:
- Full access to client medical records and limited access to financial/statistical materials.
- Maintaining client confidentiality in accordance with State and Federal laws and organizational policies.
BENEFITS:
Comprehensive benefits package includes 403(b), health, vision, and dental insurance, life insurance, long-term disability, flexible spending accounts, health reimbursement accounts, tuition reimbursement up to $1,000 annually, Employee Assistance Program, generous vacation, sick and personal days, and up to 12 paid holidays for full-time employees, with some benefits available for part-time employees.
