Registered Nurse - Care Coordination

Community Health Connections•Gardner, MA

About The Position

Community Health Connections (CHC) is a multi-site, non-profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, and substance use disorder treatment, and specialty services including optometry eye care, optical shop, acupuncture, nutrition consultations and podiatry. CHC is mission-driven, providing compassionate, quality health care regardless of income or health insurance status. CHC has five sites within Fitchburg, Gardner and Leominster with decades of experience as a Federally Qualified Health Center (FQHC), serving 36 communities in North Central Massachusetts. The Care Coordinator performs an integral role in the team-based approach to care, developing collaborative relationships with providers, patients and their significant others and other members of the care team. He /she ensures that high risk patients receive care that is consistent with national, state and health center standards and policies. The Care Coordinator supports patients and families in self-management, through evidenced-based approaches as appropriate, engages in health center projects aimed at specific patient population needs, and utilizes effective and appropriate communication strategies for issues such as health literacy and cultural norms when working with patients. The RN Care Coordinator partners with Care Coordination Specialists and interpreters to ensure that patients are able to access culturally and linguistically appropriate services in a timely and cost effective manner. He/she participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.

Requirements

Current MA RN licensure as Registered Nurse.
Bachelor of Science Nursing preferred
Experience in health education or care management preferred
Clinical experience with patients with chronic disease a plus.
Proficiency with Electronic Health Records (EHR.)
AHA BLS Health Care Provider certification
Excellent critical thinking and problem-solving skills with attention to details
Demonstrated interpersonal relationship skills
Demonstrated written and verbal communication skills in English
Demonstrated ability to work in a fast paced medical office environment

Nice To Haves

Bilingual in Spanish or Portuguese a plus

Responsibilities

Completes an initial assessment actively involving the patient to determine care coordination needs
Utilizing motivational Interviewing techniques, creates and updates care plans which address identified needs and emphasizing patient specific goals and self-management as they relate to desired medical outcomes.
Partners with patient to encourage active participation in identifying patient’s own goals
Utilizes a collaborative approach with the PCP and other team members in creating the comprehensive action plan to help ensure that the patient receives a consistent message from all team members.
Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s/families' level of independence in navigating the healthcare system at all levels of the continuum
Plans, coordinates, monitors and, evaluates progress toward meeting goals in the plan of care
Serves as a liaison and patient advocate between the providers, health center, and community resources to facilitate access to services and improve the quality of the services delivered.
Educates patient on and/or assist with establishing advanced directives
Integrates the patient/family members into care coordination and care management planning and communications, assuring the patient/family are informed and supported in decision-making.
Provides ongoing verbal and written communication of patient’s needs, plan of care, progress and changes in status with the PCP, team and the patient/family through comprehensive physical, mental and psychosocial assessments
Executes medical orders for specific drugs, treatments, and other diagnostic or therapeutic procedures
Administers and records medication administration consistent with his/her knowledge of pharmacology in accordance with health center policy
Administers routine vaccines when not administered as part of office visits.
Knowledgeable of current and catch-up vaccine schedules & complies with vaccine storage guidelines as set by the MA DPH
Participates in preventive health teaching and education pertinent to procedures being conducted
Working with the primary care provider and other members of the care team, plans and coordinates and related complications for the transition care of patients discharged from the hospital within 48 hours to prevent readmission
Under the direction of the PCP, manages tracking systems and care plans for patients admitted to and any other health care facility with the objective of preventing further disease exacerbation, improving and ER utilization outcomes, increasing patient engagement in self –care, decreasing risk status, and minimizing hospital discharged from the hospital, patients seen the emergency room, and patients transitioning from or to
Identifies and manages the patient’s primary driver (reason or problem that caused the hospitalization or ER visit) and under the PCP’s direction, assists/coordinates patient care in problem solving issues related to the health care, financial and psychosocial barriers.
Serves as a resource to non-clinical staff regarding clinical issues (i.e. phone triage)
Attends department meetings and any mandated continuing education/training programs
Maintains working knowledge of PCMH and the current requirements
Demonstrates analytic and data management skills using a variety of PC based software, including MSOffice, Word, Excel, and Power Point)
Demonstrates understanding and commitment to the mission of the health center, and established CHC values and standards
Adheres to established organization policies and procedures
Perform related duties as required and assigned.

Benefits

401k
Generous vacation and personal time for eligible employees
Sick time
Medical, dental, and vision insurance
100% paid Life insurance/AD&D
100% paid Long-Term disability.
Employee Assistance Program (EAP)
Discounts on travel and entertainment!
Discounts on cell phone service, computer purchases, and more!
College Tuition Rewards/CMEs
Company Events & Activities (Annual cookout and holiday party, health and wellness events,” Lunch & Learn’s”, team building, and more!)
EyeMed Vision Care Program
Accident & Cancer Insurance
Educational development reimbursement
Discounts on - gym membership, travel & entertainment tickets, electronics, and more!