RN Care Coordinator

Neighborhood HealthSource • Full-time • Minneapolis, Minnesota, United States • $63.23k - $79.04k / year • 5d ago

Position Summary:

The RN/Care Coordinator works in collaboration and continuous partnership with patients and their family/caregiver(s), hospitals, specialty providers and staff, and community resources in a team approach. The RN also provides supportive functions to NHS providers.

Essential Functions & Responsibilities:

General Nursing:

Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
Handles incoming triage calls:

- Provides appropriate patient education regarding medical condition

- Provides medication instructions

- Supports providers by following up with patients regarding their lab/imaging results as guided by the provider

- Documents telephone discussions in the patient’s electronic medical record (EMR)

Handles incoming Nursing Home Orders
Handles incoming pharmacy questions, clarifications and prior authorizations
Calls patients with medication changes, directions and education, as ordered by providers
Provides nursing support, when needed, to the Nurse Midwives and NHS providers
Utilizes the Patient Portal to communicate with patients
Sees patients on daily nurse schedule:

- Responds to the needs of walk-in patients

- Assists providers as needed- Provides education on medical condition, e.g., asthma, diabetes, family planning

- Reads and documents PPD results

- Provides refill requests that come through the EMR, phone or fax

-Reconciles medications

- Maintains a logbook of all dispensed medication at the direction of the medical provider

- Maintains an emergency box of medications

- Oversees the application/enrollment and tracking process for patients in indigent medication programs

- Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency

- Provides community-based nursing care as established by the organization, as requested.

Care Coordination/Case Management Support:

Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:

- Assists with the identification of “high risk” patients (those with chronic illness and/or special health care needs)

- Contacts patients to enroll them into HCH and documents patient’s acceptance or declination, to populate the registry

- Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care and educates patients on when to utilize the ER

- Reviews FUHN/ID Stratification patient’s EMR to see what patients may need; refers to specialty providers and to helps with medication reconciliation

Works with patients to plan and monitor care:

- Assesses patient’s unmet health and social needs

- Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

- Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed

- Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire

Facilitates patient access to appropriate medical and specialty providers
Educates patient and family/caregiver(s) about relevant community resources
Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals
Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider
In collaboration with the primary care provider, assigns the appropriate tiering level based on required criteria for HCH patients
Advocates for the participant in understanding needs surrounding transportation, shelter, child care and safety. Refers participant to behavioral health services if warranted
Keeps EMR care plans updated for easy access by HCH Team
Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox messaging and/or team huddles to update and advance care coordination within the Team
Utilizes all available tools to deliver education, instruction, care coordination and training, including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies & procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease management brochures; disease management participant tracking records (Diabetes glucose records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific educational handouts; services offered by NHS

Qualifications:

Graduation from an accredited nursing program
Current Minnesota RN license
Minimum one year experience in a primary care setting preferred
Patient education experience
Family planning experience highly desired
Motivated to improve the health of the community
Excellent interpersonal communication

$5k Sign-On Bonus

Benefits:

Neighborhood HealthSource offers competitive pay and benefits among community health centers. Eligible employees (24 hours/week or more) receive benefits including:

Generous paid time off and holidays
Health insurance
Life insurance
Disability insurance
Flexible spending account
Optional 403(b) retirement, vision, and dental plans
403 (b) matching- After one year, there is a 3% matching contribution that starts at 20% vesting.
Federal Loan Repayment Eligibility for Medical/Behavioral Health Providers and RNs
Mileage reimbursement for travel between clinics and to/from outreach events.

NHS IS AN AA/EOE Employer

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