Registered Nurse Team Based Care

 $5,000 Sign on bonus for eligible new hires!!! 

PRIMARY ACCOUNTABILITY:

Works with Clinic Nurse Supervisors in conjunction with Operations, Medical Providers and the Quality Improvement Team to ensure quality, comprehensive and coordinated care is delivered to patients in a PCMH/Team-Based Care environment. 

PRIMARY DUTIES AND RESPONSIBILITIES 

1) Communicates health information to patients, support staff, and team members 

a) Assists care teams with identification of complex chronic diseases and conditions to ensure the patient population receives appropriate care. 

b) Coordinates care with the medical, behavioral health and dental teams and patients to assess needs, identify barriers and coordinate plans of care and communication among multiple providers. 

c) Coordinates transitions of care with patients, PCP and other service providers. 

d) Relays appropriate information between patient and care team by documenting in EHR. 

e) Monitors and processes voicemail, EHR messaging and email in a timely manner. 

f) Works to the level of their license to maximize their contribution to Team Based Care 

g) Acts as a resource to MAs to help them work to the level of their license

 h) Acts as a leader in integrated teams to establish and maintain a positive work environment and strengthen relationships between teams and departments. 

i) Functions as an RN Case Manager in direct patient care when needed for complex patients 

j) Assists with Case Management in a Team-Based Care environment as needed under the direction of the PCP 

2) Participates in Quality Improvement and Infection Control initiatives 

a) Supports and contributes to Quality Initiatives that advance the goals of Family Health Center. 

b) Follows the direction of the Infection Control Manager to uphold the highest standards of patient and staff safety. 

c) Participates in PDSA cycles, capturing pertinent information to maximize the effectiveness of Process Improvement 

3) Patient Care 

a) Provides professional nursing care for FHC patients following established standards and practices and acting within the scope of the RN license. 

b) Interacts frequently with high-risk patients regarding care plans, by phone and in the clinical setting. 

c) Acts as an educational resource for patients and staff. 

d) Develops and discuss patient self-management plans in conjunction with PCP. 

e) Follows up with patients to assess compliance and progress with identified goals. 

f) Provides decision support and encourages treatment adherence 

g) Assists in PCMH strategies to identify high risk patients based on diagnosis and other factors; use reports to access data on high risk patients; work with Lead RN and Clinic Operations Manager (or RN SUpervisor?) to develop and implement processes to ensure high risk patients receive appropriate care at FHC. 

h) Triages patients to level of employee licensure: assess patients as needed and provide appropriate nursing care. 

4) Team Based Care 

a) Supports empanelment and helps to maintain accurate and appropriate Provider panels. 

b) Support Population Health to proactively improve the health of our community 

c) Participates in Team Based Care and Whole Person Care initiatives 

d) Works with QIP Leadership and the Clinic Nurse Supervisor to maintain compliance with all state, federal and regulatory agency standards (Joint Commission, HRSA etc) 

5) Attendance 

a) Ensures attendance and hours worked are accurately recorded in computerized timekeeping system 

b) Properly manages PTO hours. 

c) Responsible for regular, predictable attendance and to work hours as scheduled, which may include evenings or weekends 

GENERAL DEVELOPMENT 

1. Requires more advanced organizational skills, in order to organize projects or the work of others 

2. Job duties require the ability to work independently and as part of a team 

3. Job responsibilities require individual development of priorities for effective performance of duties, including re-prioritization in response to changes in circumstances. 

4. Employees are expected to determine an effective response to situations encountered with established precedent. 

5. Requires consideration of the impact of own work product on other employees involved in the workflow 

6. This position exercises leadership over others, but does not have actual supervisory authority 

PROFESSIONAL & TECHNICAL KNOWLEDGE Job duties require knowledge and training in the field of nursing typically acquired through a formal Associates degree or trade school program in nursing LICENSES AND CERTIFICATIONS Must have Registered Nurse licensure with the State of Washington