Care Management and Education Nurse

Ammonoosuc Community Health Services, Inc.•Whitefield, NH

2d•Onsite

About The Position

This onsite position has primary responsibility for the development, coordination, implementation, and evaluation of staff education programs and competency assessment processes for clinical personnel. This position will regularly travel to all 4 ACHS locations. Under the leadership of the Senior Manager of Clinical Services, the Care Management and Education Nurse is responsible for patient safety, quality, infection control, care management and staff education. Team members will have different areas of focus including transitional care management and staff development, but all members of the Care Management and Education Team will be cross trained in all of these domains. This role ensures safe, high-quality patient care and serves as a clinical resource for direct clinical support staff across ACHS sites.

Requirements

RN, LPN, MA, LNA training, education, and competency assessments
Development, implementation, and reinforcement of clinical standards, workflows, and best practices
Onboarding of clinical support staff and competency validation
Identification of learning needs and creation of improvement plans or targeted training
Adherence to patient safety and clinical quality standards
Contribution to patient safety, quality, and infection control initiatives
Support of documentation, reporting, and process improvement efforts
Serving as a clinical resource for support staff
Support of interdisciplinary communication
In-clinic coverage during staffing shortages or peak demand
Education of patients and families on disease management, treatment plans, and preventive care
Assistance with scheduling appointments, referrals, and follow-up visits
Delivery of Transitional Care Management (TCM) services
Potential expansion to Chronic Care Management (CCM), remote patient monitoring support, patient education visits, and clinic phone triage support
Prompt response to patient and staff needs
Utilization of critical thinking, nursing judgment, and assessment skills
Collaboration with Clinical Support Staff Manager for adequate resources and support

Nice To Haves

Regular travel to all 4 ACHS locations
Cross-training in transitional care management, chronic care management, and staff development
Providing direct clinical support across ACHS sites
Chronic Care Management (CCM)
Remote patient monitoring support
Patient education visits (nurse visits)
Clinic phone triage support

Responsibilities

Conduct routine and as needed training, education, and competency assessments for clinical support staff (RNs, LPNs, MAs, LNAs).
Assist in developing, implementing, and reinforcing clinical standards, workflows, and best practices.
Participate in onboarding of clinical support staff and ensure competency validation per ACHS policy.
Identify learning needs and partner with leadership to create improvement plans or targeted training.
Collaborate with clinical leadership and clinical support to ensure adherence to the highest standards of patient safety and clinical quality.
Contribute to patient safety, quality, and infection control initiatives as requested by manager.
Support documentation, reporting, and process improvement efforts related to TCM, CCM, education, and clinical operations.
Other duties, site assignments, and schedule adjustments may be required based on organizational needs.
Serve as a knowledgeable clinical resource for support staff, addressing questions related to scope, procedures, protocols, and patient care needs.
Support interdisciplinary communication to promote a culture of clinical excellence and teamwork.
Provide in clinic coverage for providers as needed during staffing shortages or peak demand.
Educate patients and their families on disease management, treatment plans, and preventive care.
Assist in scheduling appointments, referrals, and follow-up visits.
Deliver Transitional Care Management (TCM) services for patients following hospital discharge, ensuring timely follow up, care coordination, and reduction of avoidable readmissions.
May expand responsibilities (as staffing allows) to include: Chronic Care Management (CCM), Remote patient monitoring support, Patient education visits (nurse visits), Clinic phone triage support.
Respond to patient and clinical support staff needs promptly, identifying and addressing potentially urgent situations.
Utilize critical thinking, nursing judgement and proficient assessment skills to provide appropriate medical advice to patients and staff, including clinical support staff and new patient coordinators as needed.
Collaborate with the Clinical Support Staff Manager to ensure clinical staff have adequate resources and support for safe and effective patient care, including triage and workflow guidance.