E) - Ryan White Department

New Horizon Family Health Services•Greenville, SC

76d

About The Position

The Nurse Patient Care Coordinator/Educator (NPCC/E) in the Ryan White Department works with patients referred for help accessing and using health care resources because of complex chronic illness. The role supports improved health outcomes by coordinating care, educating patients, building trust between patients and medical practitioners, and improving communication and continuity of care. The NPCC/E teaches, counsels, and monitors patients on health-related issues and works with an interdisciplinary team to coordinate patient education, preventive care, and disease management. New Horizon Family Health Services operates multiple locations throughout Greenville, Greer, Travelers Rest, and Berea. Candidate placement and worksite assignments are determined at the discretion of the Executive Team based on organizational needs and operational priorities.

Requirements

Associate or bachelor’s degree in nursing, at least 3 years of work experience related to chronic disease management, and licensure as an RN in South Carolina; or a practical nursing degree, at least 5 years of work experience related to chronic disease management, and licensure as an LPN in South Carolina.
Experience in patient education and/or chronic disease management.

Nice To Haves

BSN degree in nursing.
Postgraduate training in care management, such as a Certificate in Guided Care Nursing or ANCC certification in Case Management Nursing.
Experience working in clinical outpatient settings.
Experience working with diverse population groups.
Content knowledge and expertise in the program-specific field.

Responsibilities

Complete and document a minimum of 50 face-to-face patient encounters each month.
Assess patients’ cognitive and verbal skills and identify barriers to accessing healthcare.
Provide individual and family education, including self-management goal-setting, counseling, and training on habits, lifestyle changes, supplies, and tools needed to manage disease.
Assess each patient’s educational needs and provide tools to help manage their disease effectively.
Counsel patients on office procedures, program and service eligibility, the importance of a primary care medical home, and other health issues.
Monitor patients for changes in health status following a new medication, hospitalization, or recent decline in function.
Follow up with patients when barriers to referrals are identified.
Monitor lifestyle factors affecting health, including tobacco use, substance abuse, nutrition, and physical activity, and help patients set goals for behavioral change.
Document assessments, education, goals, outcomes, and updates in the patient’s EHR for practitioner review.
Participate in interdisciplinary staff meetings to coordinate care and update the team on patients’ conditions and circumstances.
Triage and facilitate responses to urgent telephone calls, requests, or visits from assigned patients.

Benefits

Annual leave.
Sick leave.
Up to 12 paid holidays plus the employee’s birthday.
Eligibility for two annual bonuses after one year of employment when defined eligibility criteria are met.
Continuing education courses through SC AHEC.
Various employee discounts, including Verizon, AT&T, and YMCA discounts.
Eligibility for the Public Service Loan Forgiveness (PSLF) Program.
Optional medical coverage through the PEBA State Health Plan, dental coverage, and vision coverage.
Flexible Spending and Health Savings Accounts.
Voluntary life insurance.
Short-term and long-term disability coverage.
Accident and critical illness coverage.
403(b) retirement plan, with up to a 4% employer match after the first year of employment.