S UMMARY: The Clinic RN position provides health advice, education and care coordination for SBNC patients in person, over the phone and via the patient portal. This position is an integral part of the Patient Centered Medical Home (PCMH). The RN will support chronic disease management efforts to support optimal patient outcomes. E S S E NTIAL DUTIES AND RESPONSIBILITIES CLINIC RN: P r ovides excellent customer service in all phone and other interactions Collaborates with patients primary care team as needed to coordinate appropriate care Retrieves messages in a timely manner and responds to patient needs according to medical priority Reacts in a positive manner to patient concerns; remains calm and displays empathy W o r k s cooperatively with other staff and departments to problem solve and improve workflows Maintains patient confidentiality/HIPAA P articipates in required meetings P r ovides culturally sensitive, patient-centered case to all SBNC patients A ss i s ts in the development, maintenance, revision and evaluation of clinic workflows E l i c i ts history of present illness and pertinent past medical history and uses clinical judgment and experience to formulate a care plan Coordinates follow-up care for patients with recent emergency department visits or hospitalizations S ends medication refills per clinic protocol Utilizes health coaching skills and encourages patient activation and self-management Help patients manage medications accurately and safely. RN is authorized to remove and update medications with Provider input Discuss test results per provider order Participates in outpatient case management of medically or psychosocially complex patients; visits may take place within the home. Maintains accurate charting and registry of all patients served under case management. Provides health education and formulates care plans for patients and families; and support with chronic illness e.g. diabetes, asthma, heart failure, obesity, etc. Delegates patient outreach, teaching and care coordination activities to the LVN as appropriate Facilitates and implements clinic focus quality improvement and evaluation initiatives. Contributes to a work environment where continuous quality improvements in service and professional practice are pursued Identifies, collects and maintains timely and accurate information about the clinics quality improvement activities Conducts monthly MA chart reviews for various functions related to workflow, screenings, utilizing the audit E S S E NTIAL DUTIES AND RESPONSIBILITIES PANEL MANAGEMENT: P anel management is an organized, population-based, data driven multi disciplinary team approach to quality patient care Utilizes a disease registry to identify patients unmet care needs, to gather summary information for care i nterventions, and to communicate with patients Uses health coaching techniques, standing orders, patient outreach and community resources to improve patient engagement and patient outcomes. Reviews and follows up on Emergency Department and Hospital discharge summaries to facilitate coordination of transition to home W o r k s as a team with other clinic staff to develop, maintain, and revise workflows to support improvements in missed care opportunities. The above statements are intended to describe the general nature and level of work being performed by most people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties, and requirements. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or it is a logical assignment to the position. The employee is expected to perform other duties necessary for the effective operation of the department.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
51-100 employees