Job Description

SUMMARY:

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.

ESSENTIAL DUTIES AND RESPONSIBILITIES – CLINIC RN:

• Provides 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
• Works cooperatively with other staff and departments to problem solve and improve workflows
• Maintains patient confidentiality/HIPAA
• Participates in required meetings
• Provides culturally sensitive, patient-centered case to all SBNC patients
• Assists in the development, maintenance, revision and evaluation of clinic workflows
• Elicits 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
• Sends 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 clinic’s quality improvement activities
• Conducts monthly MA chart reviews for various functions related to workflow, screenings, utilizing the audit

ESSENTIAL DUTIES AND RESPONSIBILITIES – PANEL MANAGEMENT:

Panel 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 interventions, 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
• Works 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.

QUALIFICATIONS AND EDUCATION REQUIREMENTS:

• Qualifications: Current CA RN License in good standing. Current AHA CPR Certification. Bilingual in English/Spanish preferred
• Education: Associate or BA/BS Degree
• Experience: Five (plus) years of direct patient case management and/or community health experience.

• Knowledge & Skills: English grammar, spelling, and punctuation must be excellent. Excellent Documentation skills. Communication skills (written and verbal). Strong Critical-thinking skills. History-taking skills. Good organizational skills

• Ability to: Follow verbal and written instructions accurately. Communicate effectively and professionally with a variety of people and provide accurate information, via phone, e-mail, and written communication. Work independently and complete tasks with minimal supervision. Pay attention to detail. Strong enthusiasm and willingness to pitch in whenever needed. Organize work and maintain accurate files and records. Use office equipment including copier, fax, and postage meter. Functions well in a high-stress environment.

• Physical Demands: May be required to lift objects weighing up to 25 pounds. Sitting in a normal seated position for extended periods of time. Reaching by extending hand(s) or arm(s) in any direction. Finger dexterity required to manipulate objects with fingers rather than with whole hand(s) or arm(s), for example, using a keyboard. Communication skills using the spoken word. Ability to see within normal parameters. Ability to hear within normal range. Ability to move about.

• Certification/License: Valid California driver’s license.

The physical demands described above are representative of those that must be met by an employee to successfully perform the essential function of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job unless providing such accommodations would result in undue hardship for the SBNC.

Salary Range: $51 - $56

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