Chronic Care Management Registered Nurse

PUEBLO COMMUNITY HEALTH CENTER INC • Pueblo, CO

116d • $31 - $37

About The Position

The Chronic Care Nurse is a vital member of our interdisciplinary team, responsible for managing high risk, chronic illness patients to promote high-quality, patient-centered care to improve health outcomes, reduce avoidable hospitalizations, and enhance overall quality of life for individuals served by PCHC.

Requirements

• Registered Nurse with a valid and unrestricted Colorado license.
• Current B.L.S. with skills demonstration C.P.R. certification for Healthcare Providers required.
• Experience in care coordination, case management, or chronic disease management preferred.
• Previous experience with adult health and/or management of chronic conditions preferred.
• Valid driver’s license and auto insurance as required by law.

Responsibilities

• Ensure the function and activities of this department to embrace the philosophy, mission, values, and Communicate with Heart service model supported by the Board of Directors of Pueblo Community Health Center, Inc.
• Adhere to PCHC policies, including Infection Control and Nursing Policies and Procedures.
• Conduct comprehensive assessments of patients’ medical, psychosocial, and functional needs.
• Develop, implement, and monitor individualized care plans in collaboration with patients, families, and healthcare providers.
• Act as a liaison between patients, primary care providers, specialists, and community resources to ensure seamless care transitions.
• Schedule and follow up on referrals, tests, and treatments to promote adherence to care plans.
• Educate patients and caregivers on disease management, medication adherence, and lifestyle modifications.
• Monitor clinical indicators (e.g. blood pressure, A1c levels) and provide timely interventions as needed.
• Serve as an advocate for patients by addressing barriers to care, including transportation, insurance issues, and access to medications.
• Promote health equity by connecting patients with culturally appropriate resources and services.
• Document all care coordination activities in the electronic medical record (EMR).
• Analyze patient data to identify trends, monitor outcomes, and contribute to quality improvement initiatives.
• Participate in regular team meetings to discuss care plans, review patient progress, and identify opportunities for enhanced care delivery.
• Respond promptly to critical labs or provider calls via designated communication channels.
• Navigate and document patient care using EPM and EHR systems, ensuring compliance with workflow guidelines.
• Facilitate communication and teamwork within integrated care teams, including MAs, Medical Support Partners, Care Coordinators, and providers.
• Perform nursing care tasks under provider direction, including medication administration, wound care, EKGs, point-of-care testing, and procedural assistance.
• Collaborate in Medicare Annual Wellness Visits by pre-screening and scheduling eligible patients.
• Oversee and assist with patient intake processes, including reviewing health histories and medications.
• Attend mandatory meetings.

Benefits

• Competitive hourly wage
• Opportunities for professional development
• Supportive work environment

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Bachelor's degree
• Number of Employees: 101-250 employees