Description

PRIMARY FUNCTION: 

The Registered Nurse (RN) provides patient centered care which includes care coordination and health education to patients and their families utilizing the nursing process of assessment, planning, intervention, and evaluation. 

The RN will work in a clinical triad with the Medical Assistant (MA) and Medical Provider (MD/DO/NP/PA). This position also works closely with an interdisciplinary team including the medical care teams, Integrated Health team, Dental staff, Member Services and outside referral entities to ensure patient centered care.

The RN also plays an essential part in the clinic attaining the goals that administration has set forth for reaching Patient Centered Medical Home recognition, UDS standards and third-party incentive programs. The RN will do this in a team-based care model by functioning in the team as the primary care facilitator.

ESSENTIAL RESPONSIBILITIES:

Clinical Responsibilities:

Pre-Visit Patient Care:

• Follows the pre-visit planning policy and procedure as established by the organization.
• Coordinates pre-visit planning with Medical Assistant and Medical Provider on assigned team.
• Prepares for, attends and participates in team meetings and huddles.
• Works with Medical Assistant to contact all new patients presenting with Chronic Disease indicators, 5 to 7 days prior to their first visit in order to complete a Pre-Visit assessment that includes medications, past medical history, medication list and problems. Completes screenings for depression, smoking, drugs, safety, etc. per current practice guidelines.
• Identifies High Needs Patients, described below, with Medical Provider and works with Medical Assistant to contact all identified High Needs Patients, 5 to 7 days prior to next visit to determine if care plan objectives from previous visit have been completed, if there has been interim care outside the organization and if the patient has any concerns that the team can prepare for.

Patient care during visit:

• Confers with Medical Provider on team and participate in data gathering, setting patient expectations, patient education and care coordination of High Needs patients, as requested by the medical provider. These will consist of:
• • Transfer of Care (TOC) Patients:
    • New Patients
    • Hospital/ER Follow ups
  • Patients with poor control of chronic medical conditions
  • Patients with anticipated barriers to data gathering of patient history and care needs:
    • Language barriers
    • Learning or cognitive disabilities
    • Mental Health or Behavioral barriers
• Patients with multiple specialist care providers
• Patient with high acuity care-coordination (e.g. patients with active cancer diagnosis)
• Time intensive patients (as designated by the medical provider).
• Conducts RN-led chronic care management visits. The RN will review population health data for the panel entrusted to the assigned care team with the Medical Provider.
• Identifies patient care needs based on assessments and conversation with the patient and family.
• Verifies the patient history, medication list, problems, and diagnostic test results and identify any care gaps.
• Monitors and facilitates preventive care such as immunizations, cancer screenings and lab tests.
• Conducts Medication Reconciliation for all High Needs Patients, RN-led Visits and per provider request.  Gives report to provider, using SBAR method, about patient care needs.  Collaborates with care team and patient in developing team priorities, patient goals and care plans.
• Assists the patient in setting realistic self-management goals taking into consideration barriers the patient and family may encounter.
• Assists the patient in obtaining needed services in the community such as transportation, house etc. by referring the patient to the appropriate organization and monitors results.
• Documents in EMR the RN interaction with patient, according to organizational policy and protocol.
• Assists provider with procedures as needed and within scope of practice.

Patient Care In Between Visits:

• Utilizes the EMR and population health tools to identify significant care gaps and take steps to facilitate patient and population management to improve clinical outcomes as identified by clinical quality measures (CQM).
• Notifies patients, per provider instruction, of abnormal test results and follow plan.
• Assists the team in monitoring and responding to the Refill Line, per organizational Refill Policy and Protocol.
• Will be responsible for on-going care coordination of patients as requested by patient (or designated proxy), Medical Provider and other referral entities/diagnostic centers/agencies involved in care of the patient.

General Clinical Responsibilities:

• Provides nursing triage.
• Medication and vaccine administration.
• Responds to phone calls in a timely manner and per protocol.
• Responds to life threatening situations within the scope of licensure.

Quality and Safety:

• Participates in self-education needed to perform case management and patient care.
• Participates in meeting the quality clinical measures set by the organization by reviewing preventive care needed and protocol tests, as needed.
• Participates in quality initiatives as directed to fulfill the organizations grant obligations and insurance requirements.
• Practices within the Clinical Protocols and Guidelines and Policies and Procedures of the organization.
• Participates in Emergency Preparedness Plan.

Other:

• Other duties, as assigned, and within the scope of licensure.

QUALIFICATIONS:  

To perform this job successfully, an individual must be able to perform each essential job function assigned satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education: 

• Graduate of an accredited school of Licensed Professional Nursing
• Licensed in the State of Hawaii as a Registered Nurse

Experience: 

• Two (2) or more years’ experience as a Registered Nurse preferred.
• Experience or training in case management preferred.
• Prior experience and familiarity with the population and the needs of the community.
• Must understand the fiscal and programmatic administration of a federally funded Community Health Center.
• Must understand the needs of the consumer and understand the complex management of a diverse, community-based health care program.

Skills/Competencies:

• Excellent verbal and written communication skills.
• Ability to plan and organize small and large scope projects.
• Ability to make accurate assessments and prioritize work to be done.
• Must have ability to logically analyze and rationalize issues of a complex nature and make decisions with large ramifications.
• Must possess strong leadership skills and ability to solve problems.
• Computer literate in word processing and spreadsheets. Knowledge/skills of basic computer operations, i.e. word processing, data base, including using Microsoft Word and Excel to create reports and graphs.
• Provide excellent customer services to our clients including demonstration of the organizational value that patient needs are the first and central priority and the belief that patients come first.
• Willingness to assist co-workers.

Other requirements:

• Valid Driver License
• Access to an insured vehicle
• Current BLS CPR/AED certification
• TB Clearance within the past 12 months
• Fully vaccinated against COVID-19 or approved medical or religious exemption

Requirements

2 years experience in nursing preferred; will consider new grad.