Provide skilled nursing care, assessment, care planning, care management and coordination of the plan of care for a specified population of patients in need of intensive care management. Work with CCA regarding MDS-Home Assessments and identification of Tier 2 Dual eligible patients.
- 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.
DUTIES AND RESPONSIBILITIES:
- Based on patient assessment, initiates care plan for patients coordinating services to ensure continuous, comprehensive care.
- Collaborates with all members of the health care team.
- Reviews cases with the PCPs on a regular basis.
- Initiates appropriate referrals to additional services including home care and notifies appropriate support staff of referrals to ensure authorization.
- Coordinates medical/health care appointments. Assists patients to obtain access to transportation.
- Researches, evaluates and recommends community resources to meet non-medical needs of patients, i.e. alternative resource programs, support groups and community support resources. Refers to CCA staff as appropriate.
- Reviews and recommends for approval, as appropriate, all services requiring prior approval from DMA.
- Works with the PCP, inpatient providers, discharge planners and nurse partners to ensure efficient use of inpatient resources and a timely discharge to an appropriate setting. Makes onsite visits as indicated.
- Facilitates and participates in patient care conferences for medical and peer review. Identifies and triages PCCP members who would benefit from an intensive care management model.
- Collaborates with behavioral health care providers to ensure coordination of medical and behavioral health care.
Functions as a primary care nurse to a specified population of patients in need of intensive care management:
- Completes a comprehensive assessment on new members.
- Evaluates the needs of each patient, develops and implements a plan of care that optimizes outcomes in conjunction with the PCP. The plan reflects goals identified by the care manager, the patient, family, PCP and other providers involved in the patient’s care.
- Makes home visits to monitor each patient’s clinical status. Assesses the status of identified problems, response to treatment, compliance with therapeutic regimes and medications and progress towards goals. Refers to the primary care provider and team as needed.
- Provides expert nursing care.
- Sees patients in the practice setting with the PCP or specialist when indicated.
- Participates in the planning, implementation and coordination of health education and counseling of the patient and family. Teaches families and caretakers how to provide safe, effective care and promote optimum function for patients in the home. Documents the level of understanding and response to teaching.
- Advocates for patients in a culturally competent manner.
- Ensures that patients’ rights to fair and equitable treatment and self determination are well established and maintained.
- Seeks maximum patient and family participation and independence.
- Manages the caseload effectively, establishing a daily work plan based on patient priorities of service and caseload needs.
- Provides telephone triage for clinical concerns of patients, care providers, family and significant others.
Maintains appropriate written and oral communication on a timely basis:
- Documents patient encounters within established timeframes.
- Updates the care plan appropriately.
- Documentation is clear, objective and reflects the delivery of safe, quality care.
- Communicates the patients’ clinical status to the PCP on a regular basis.
- Promptly communicates changes and/or new problems to the PCP.
- Establishes and maintains an ongoing positive working relationship with all members of the health care team.
Participates in assessing and improving quality within the scope of responsibilities and throughout the organization as appropriate:
Participates in quality improvement activities as required.
Advises appropriate personnel of quality issues and problems and makes recommendations for improvement.
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.
- RN with current Massachusetts License.
- Bilingual preferred.
- Demonstrated ability to work in the community and to manage multiple assignments and meet deadlines.
- Minimum of 2 years clinical experience in acute care/medical surgical settings.
- Significant experience in home care and/or community settings.
- Discharge planning and case management experience desired.
- 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.
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 # 19-076