Care Team Nurse

Alexander Valley Healthcare•Cloverdale, CA

2d•$80,000 - $133,120

About The Position

This role involves working as part of a clinical nursing team to deliver comprehensive nursing services. Key responsibilities include patient assessment, providing phone advice, managing cases, coordinating care within the team, and educating patients. The nurse will also review laboratory and diagnostic imaging results, manage medication refills, monitor patient referrals, and resolve telephone encounters within a specified timeframe. Additionally, the position requires monitoring provider schedules, managing population health activities, overseeing vaccine programs, developing care plans to improve patient outcomes and reduce utilization of hospital services, and utilizing behavioral strategies to promote healthy behaviors. The role also involves assisting patients with healthcare system navigation, financial and psychosocial barriers, documenting patient progress, communicating care plans with the healthcare team and patient/family, managing care coordination systems, supervising behavioral health services, participating in care team meetings, and providing leadership to support staff. Professionalism and excellent customer service are expected, along with monitoring of crash carts and AEDs. Other duties may be assigned.

Requirements

High School Diploma or Equivalent.
Valid RN or LVN California License in good standing with the California Board of Nursing.
CPR Certification.
Ability to read, write, and communicate in the English language.
Broad knowledge of principles and practices, care coordination or case management.
Must possess excellent time management, organizational, and work planning skills.
Knowledge of personnel management principles.
Knowledge of health care regulations and guidelines.
Demonstrated experience in a healthcare, mental health, or social work related field, or any satisfactory combination of experience and training which demonstrates the knowledge, skills and abilities to perform the above duties.

Responsibilities

Work as part of the clinical nursing team to provide a full range of nursing services, including patient assessment, phone advice, case management, care team coordination, provide patient education.
Review provider/clinician laboratory results on a daily basis, identifying and communicating common items to patients or provider per organizational protocol.
Review provider/clinician diagnostic imaging reports received from outside agencies and communicate to patients or provider per organizational protocol.
Refill medications for care team patient panels per established Nursing Protocols.
Monitor care team patient panels referral status, ensuring documentation is complete, patient compliance or barriers are addressed, and referral completion is documented.
Work to resolve telephone encounters within 72 business hours of receipt.
Monitor support team and nurse schedule for appropriate appointment types and cycle times.
Notify patients of test results and follow up plan per protocol or as directed by provider/clinician.
Monitor provider's schedules in the care team for available daily access for each care team provider/clinician and that each appointment is appropriate for each individual provider's scope of services.
Monitor population management activities by support staff, ensuring documentation is complete and interventions are identified in the patient's health record.
Ensure effective management of the vaccine/immunization programs.
Develop care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize unnecessary hospital inpatient and ER utilization.
Utilize behavioral strategies, such as motivational interviewing, to assist patients in adopting healthy behaviors, improving self-care, managing chronic disease, and utilizing in-house resource.
Assist patients in problem-solving issues related to the health care system, financial and psychosocial barriers.
Provide ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of follow-up care.
Communicate/affirm patient needs, plan of care, and changes in status with the patient's PCP, team, and the patient/family.
Manage care coordination systems for referrals, ordered test completion, and receipt of report from outside providers.
Supervises and supports integrative behavioral health services.
Participate in care team meetings to evaluate outcomes of care with the care team.
Provide leadership to care team support staff.
Model professionalism and excellent customer service standards.
Monitoring of Crash cart/AED.
Other duties as assigned.