Chronic Care Registered Nurse

2 weeks ago


Austin, Texas, United States Central Health Full time

Position Overview


In partnership with patients, their families, and interdisciplinary staff, this role is accountable for overseeing all elements of patient-focused care for individuals with chronic health conditions.

Engages closely with patients, caregivers, physicians, and healthcare teams to ensure effective long-term care coordination and cost management for those with chronic illnesses.


Key Responsibilities

Essential Duties (a minimum of 5 critical responsibilities necessary for successful job performance):

  • Evaluate the status of patients and primary caregivers through thorough interviews tailored to the assigned program.
  • Formulate and communicate a detailed care strategy in collaboration with the patient, caregiver, and primary care team, based on evidence-based practices for chronic illness management.
  • Regularly monitor the patient's health status or as outlined in program protocols.
  • Oversee and coordinate all transitions between various care sites and providers as necessary according to program guidelines.
  • Provide education and support to patients and their family caregivers in alignment with program standards.
  • Facilitate patient access to community resources and services.
  • Deliver direct nursing care as required by program specifications, including administering medications and treatments in accordance with established care standards.
  • Conduct patient triage as needed.
  • Enhance patient outcomes through effective care coordination with other healthcare providers, ensuring that care plans are properly implemented.
  • Proactively manage and follow up with patients in accordance with the established care plan.
  • Complete all necessary documentation for direct and indirect patient care promptly, ensuring that patient records are accurate and up-to-date.
  • Participate in daily patient care huddles and periodic meetings related to quality assurance, patient care, and other relevant topics.
  • Attend educational seminars and maintain all licensure and certification requirements for ongoing professional development and best practices.
  • Engage in quality improvement initiatives to assess compliance with evidence-based guidelines and identify opportunities for enhancing patient outcomes.
  • Ensure that all tasks related to patient care and administrative processes comply with regulatory and accreditation standards.
  • Foster positive internal relationships and partnerships with colleagues, including clinical managers, support staff, and providers.
  • Interact respectfully and collaboratively with patients and their families, aiming to build strong relationships.
  • Collaborate with all members of the healthcare team to deliver patient-centered care.
  • Perform additional duties as assigned.

Knowledge, Skills, and Abilities:

  • Exceptional relationship-building skills and a commitment to providing outstanding customer service.
  • Comprehensive knowledge and proficiency in nursing practices and documentation requirements.
  • Necessary skills and capabilities to perform specific medical tasks as assigned.
  • Strong problem-solving abilities to enhance service delivery for patients and staff.
  • Meticulous attention to detail and accuracy.
  • Excellent verbal and written communication capabilities.
  • Proven track record in delivering high-quality nursing practices and fulfilling assigned duties.
  • Demonstrated experience in managing multiple nursing responsibilities simultaneously.
  • Experience with direct patient care and familiarity with medical devices and equipment.
  • Proficient in using technology and systems commonly found in healthcare settings (e.g., personal computers, spreadsheets, word processing, patient record systems, EMR systems).

Qualifications

Minimum Education:
Graduation from an accredited nursing program.

Preferred Education:

Bachelor of Science in Nursing (BSN)

Minimum Experience:
At least 2 years of clinical nursing experience.

Required Certifications/Licensure:

  • Valid nursing license in the state of Texas.
  • Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification from a recognized organization, with the requirement to maintain certification throughout employment.


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