*This position is funded through the Prevention and Wellness Trust Fund (PWTF) grant*
Provide skilled nursing care, care management and coordination of the plan of care for a specified population of patients in need of these sevices.
DUTIES AND RESPONSIBILITIES:
- Identify patient need for care management and/or care coordination. Assess complexity using standardized tool, based on data from patient and other appropriate sources, such as claims data reports, hospital reports, providers, EHR, registries, medication lists, grants, etc.
- Develop and carry out care plan collaboratively with the patient, patient’s family, primary care team and other health providers. Involve patient in decision making process.
- Identify barriers to health improvement, problem solve and explore options for improving care.
- Facilitate communication and coordination of care among members of the patient’s health care team, internal and external.
- Provide education to patient and significant others on medication and disease management strategies.
- Provide direct skilled nursing services as needed.
- Coordinate referrals and community resources as needed.
- Facilitate communication of pertinent clinical information when patient transfers to or from other health settings, with special attention to post-hospital follow up and medication reconciliation.
- Document all patient contact and care management activity in the EHR per health center policies.
- Educate patient on appropriate use of services as needed to reduce cost and improve outcomes.
- Update care plan and evaluate outcomes appropriately.
- Promptly communicate and collaborate with members of the health team to assess need for ongoing changes in services, based on patient’s changing health status.
- Advocate for patient to receive quality care. Encourage or educate patient on self management and self-advocacy skills.
- May perform home visits as needed to assess patient’s clinical status in the community.
- Attend all meetings as directed by supervisor.
- Maintain professional relationship with vendors and colleagues.
- Participate in quality improvement initiatives and other health center activities as requested by supervisor.
- Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service training.
- Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
- Appropriately handles or seeks support when customer service breakdowns occur.
- Demonstrates a knowledge of culture by successfully completing the on-line training on Cultural Competence.
- Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
- Responds appropriately or seeks support when confronted with cultural biases or conflicts.
- In order to respond promptly and appropriately to emergency situations, any staff member may be assigned temporary duties which differ from those in the job description, or may be assigned temporarily to a different location or schedule.
- Reports to Director of Care Management programs or designee
- RN with current Massachusetts License.
- Bilingual preferred.
- History of good attendance and positive work attitude.
- CCM or CCM eligible preferred.
- Minimum of 2 years clinical experience in acute care/medical surgical settings preferred.
- Significant experience in home care, Behavioral Health and/or community settings preferred.
- Case management experience preferred.
- Knowledge of BH diagnoses.
- The essential job duties of this position present risk of exposure to body fluids and blood borne pathogens. Annual LCHC Bloodborne pathogen training is required.
- Hepatitis B vaccine is strongly recommended and available at no charge at the Health Center.
- Declination form must be signed if this vaccine is declined.\
- Participate in LCHC community outreach efforts, as appropriate and as assigned. This may include serving as a health consultant for the Lynn Public Schools, local day care centers, after school program, day camps or other community related organizations; providing such services as programmatic consultation, preparation/review of health related policies and documentation or participating in health screenings, health education programs or counseling at health fairs and other similar community events.
- Proven skills and knowledge base necessary for clinical decision making and care delivery.
- Ability to function independently and seek assistance with unusual problems.
- Excellent organizational skills.
- Strong interpersonal and customer relations skills.
- Effective teaching skills.
- Respect and maintain patient confidentiality in all aspects of care including use of electronic information.
- Treat all patients in a welcoming and professional manner.
- Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
- Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
- Welcome new employees and students to the team by assisting with their orientation to the team and mentoring them, as requested by NCM Supervisor.
Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge.
Job Posting ID # 17-107