E) - Ryan White Department

New Horizon Family Health Services•Greenville, SC

8d•Onsite

About The Position

The NPCC/E works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illness. This position supports improvements in health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. The NPCC/E will teach, counsel and monitor patients on issues relevant to their health. As a member of an interdisciplinary team, this position will consult with other health care team members to coordinate the provision of patient education, preventive care and disease management.

Requirements

Associates or Bachelors Degree in Nursing and 3 years work experience related to chronic disease management and licensure as an RN in South Carolina or, Practical Nursing Degree, 5 years work experience related to chronic disease management and licensure as an LPN in South Carolina
Experienced in patient education and/or chronic disease management

Nice To Haves

BSN Degree in Nursing
Post graduate training in care management such as a Certificate in Guided Care Nursing or ANCC certification in Case Management Nursing
Experience working in clinical out-patient settings
Experience working with diverse population groups
Content knowledge and expertise in program-specific field

Responsibilities

Complete and document a minimum of 50 face-to-face patient encounters each month.
Assess cognitive/verbal skills and identify barriers to accessing healthcare.
Provide individual and family educational interventions including self-management goal-setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease.
Perform individualized assessment of a patient’s educational needs and provide tools to aid in managing their disease(s) effectively.
Provide individual counseling on office procedures, eligibility for programs/services, importance of a primary care medical home and other health issues.
Monitor patients for changes in health status after initiation of a new medication, a hospitalization or recent decline in function.
Follow-up with patients when barriers to referrals are identified.
Monitor lifestyle factors affecting health – such as tobacco use, substance abuse, nutrition and physical activity – and assist the patient with goal-setting to achieve behavioral change.
Document assessments, education, goals, outcomes and updates in the patient’s EHR for review by their practitioner.
Participate in staff meetings focused on coordinating patient care within an interdisciplinary team, keeping the team updated on a patient’s condition and circumstances.
Triage and facilitate response to urgent telephone calls, requests or visits from assigned patients.

Benefits

Annual Leave
Sick leave
Up to 12 Paid Holidays plus your birthday
Eligibility for 2 annual bonuses after 1 year of employment when defined eligibility criteria are met
Continuing education courses through SC AHEC
Various employee discounts. I.e., Verizon, AT&T, YMCA, etc.
Eligibility for the Public Service Loan Forgiveness (PSLF) Program
Medical (PEBA State Health Plan), Dental and Vision benefits
Flexible Spending and Health Savings Accounts
Voluntary Life Insurance
Short Term Disability and Long Term Disability
Accident and Critical Illness Coverage
403 (b) Retirement Plan, with up to 4% employer match after the first year of employment