Job Description
Responsibilities and Duties: - Provides service to patients of Community Memorial Hospital five outpatient Family Health Centers (Morrisville, Waterville, Munnsville and Cazenovia, Sherrill).
- Responsible for managing a patient’s successful transition from hospital & long-term care to primary care services. Manages the post-acute care of patients at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions.
- Coordinates with CMH Care Coordination team to identify hospitalized high-risk, complex patients for program enrollment and communications with primary care to promote and maximize care coordination. Serves as a member of the CMH Readmission Committee.
- Completes post-discharge workflow of telephonic follow-up within 48 hours, facilitating clinical care, patient access to appropriate services, referrals and primary care appointments with 14 days. Focuses on medication reconciliation and adherence, identification and rectifying gaps in care, assessment and support of patient’s ability to perform self-care, coordination of post-discharge appointments and services.
- Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care. Advocate for patient(s) and supporting clinical team(s) to ensure delivery of appropriate, evidence-based care.
- Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures. Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
- Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
- Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
- Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
- Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
- Provide clinical experience in an educator role for family health center nursing staff. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.
- Facilitate Quality Improvement activities that educate, support, nursing, regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010).
- Collaborate with Practice Manager and FHC Administration team in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.
Job Requirements: - RN with three to five years relevant clinical nursing experience; including pediatric patients, behavioral health patients, and patients with chronic conditions.
- Organized and motivated by a fast-paced environment
- Able to manage multiple tasks/projects simultaneously
- Proficient in review and assess needs quickly
- Strong with the use of computer software tools and data files
- Comfortable with continuous change and self-initiating
- Maintain strict confidentiality
- Build effective and trusting relationships with patient/peers
- Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
- Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
- Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
- Use data to analyze trends and to verify data
- Ability to promote programs and services to community
- Proficient in review of medical records and other patient care information
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
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Job Tags
Temporary work