High Risk Care Manager, Registered Nurse (.8 FTE)

Neighborcare Health•Seattle, WA

3d•$44 - $55•Onsite

About The Position

The Registered Nurse works in partnership and joint accountability within an interdisciplinary team to achieve Neighborcare’s Mission, Guiding Principles and goals. The primary focus of the RN, High Risk Care Management is to optimize the health status of patients through focused care management, including chronic condition management and transitions of care. RNs build relationships with their patients through face-to-face and telephonic care and work in partnership with other care team members to meet the needs of patients throughout Neighborcare Health. The RN follows the Nursing Process to assess, plan, implement and evaluate nursing care in a Patient Centered Medical Home.

Requirements

Knowledge and understanding of a broad range of physical and mental health conditions throughout the lifespan
Ability to work effectively with patients and communicate effectively and respectfully with people of varied cultures, ethnic, language (including use of interpreters), educational and socio-economic backgrounds as well as individuals with disabilities and contagious diseases
Knowledge, skill and ability to provide pregnancy and contraceptive options counseling
Knowledge of medical terminology and clinical procedures; anatomy, physiology, biology, human growth and development; asepsis and universal precautions; medical documentation
Ability to demonstrate reliable and timely attendance
Ability to start and operate emergency equipment, perform CPR, and provide basic first aid, and respond professionally in emergent situations
Skills in the use of personal computers, Electronic Health Records, e-mail, and other software programs and reports
Skills in written and verbal communication in English and basic math
Ability to comply with HIPAA/Confidentiality policies and procedures and to handle confidential and sensitive patient and staff information
Ability to work effectively independently and as part of a team, interact appropriately with co-workers and patients, and develop and maintain rapport with a wide range of individuals
Ability to demonstrate flexibility, adaptability, willingness and openness to learn and change
Ability to follow written and verbal directions and to complete assigned tasks in a timely manner
Ability to be detail-oriented and handle multiple tasks under stressful conditions, including organizing and problem solving in a creative manner
Ability to demonstrate sound clinical judgment and work resourcefully and independently in the absence of detailed instructions
Ability to work with supervision, receiving instructions/feedback, coaching/counseling and/or action/discipline and learn from directions, observations and mistakes
Ability to effectively perform job duties under a variety of conditions including time and/or resource constraints
Ability to self-assess knowledge and nursing skill, and continuously develop clinical expertise through Neighborcare Health and community-based Continuing Education
Completion of an accredited RN program
Valid Washington State Registered Nurse license
BLS certificate
2 years RN experience in a primary care, hospital and/or home care setting or comparable social service setting

Nice To Haves

Skills in Motivational Interviewing and application of a harm reduction model
Knowledge of unique health needs of specific patient populations pertinent to the role/site
Knowledge of community resources
BSN desirable
Board Certification in applicable specialty areas
3+ years RN experience in a primary care, hospital and/or home care setting or comparable social service setting
Prior experience in care management, transitions of care management, and/or discharge planning

Responsibilities

Provide care to defined panels of patients in the outpatient clinic setting and work as members of Neighborcare’s nurse team
Maintain joint accountability to the clinic team and to the medical program as a whole, to include supporting colleagues throughout the organization either on site or remotely as needed
Work with team members and leaders to define and reassess priorities and plan, communicate, and execute care delivery
Participate in Quality and Performance Improvement efforts at the site/program to improve patient outcomes
May serve as a preceptor for new staff and/or students who are assigned to Neighborcare as part of their professional education
Participate in the design, pilot, and implementation of Neighborcare’s Patient Outcome Panel Support, a team-based Care Management model
Follow the Plan-Do-Study-Act approach to continuous improvement in partnership with Neighborcare Health Quality team
Research and apply best-practices and community standards for Care Management
Develop and share subject-matter expertise in Neighborcare POPS processes with other members of the care team
Establish partnerships with patients and families in person and via telephone for positive outcomes in health status
Identify patient goals for improving their health status and management of chronic physical and mental health conditions
Assess patient understanding of their condition and readiness to change
Provide patient with education about the disease process; offer tools and skills needed to achieve self-management goals
Monitor, track, and follow-up with patients to ensure care needs are met utilizing patient panel reports
Coordinate care with outside providers and resources
Apply Neighborcare Health guidelines and standing orders and evidence-based clinical practices
Provide patient education across the lifespan in person and over the phone (select roles may focus on specific patient populations, including pediatric, perinatal, or individuals experiencing homelessness)
Assess barriers to learning and tailor education to meet patients’ individual learning styles and needs
Educate patients about medications, abnormal laboratory results, and self-management of acute and chronic conditions
Promote wellness and the importance of preventive care
Provide motivational interviewing and harm reduction counseling