Chronic Care Management Registered Nurse na Pueblo Community Health Center Inc

Description

Chronic Care Management Registered Nurse

Starting Pay Range $31.77 – $37.38 per hour

Job Summary:  The Chronic Care Nurse is a vital member of our interdisciplinary team, responsible for managing high risk, chronic illness patients to promote high-quality, patient-centered care to improve health outcomes, reduce avoidable hospitalizations, and enhance overall quality of life for individuals served by PCHC.

Reports to:  Clinical Nurse Manager

Supervision Exercised:  None

Education/Experience/License/Certification:

• Registered Nurse with a valid and unrestricted Colorado license.
• Current B.L.S. with skills demonstration C.P.R. certification for Healthcare Providers required.
• Experience in care coordination, case management, or chronic disease management preferred.
• Previous experience with adult health and/or management of chronic conditions preferred.
• Valid driver’s license and auto insurance as required by law.

Required Travel:  Occasional local travel may be required.

Knowledge/Skills/Abilities:

The following requirements represent the essential knowledge, skills, and abilities necessary for the position. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions.

1. Communication:
   1. Strong verbal communication skills, including the ability to understand, present, and exchange information clearly.
   2. Proficiency in reading, interpreting, and composing written materials such as patient care instructions, policies, and reports.
2. Cognitive Abilities:
   1. Excellent memory retention to apply procedures, policies, and clinical guidelines effectively.
   2. Analytical skills, mathematical reasoning, and problem=-solving abilities to manage clinical and administrative tasks.
   3. Strong understanding of chronic conditions such as diabetes, hypertension, COPD, and cardiovascular disease.
3. Organizational Skills:
   1. Exceptional ability to prioritize tasks, maintain accurate records, and manage multiple responsibilities effectively.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

1. Ensure the function and activities of this department to embrace the philosophy, mission, values, and Communicate with Heart service model supported by the Board of Directors of Pueblo Community Health Center, Inc.
2. Adhere to PCHC policies, including Infection Control and Nursing Policies and Procedures.
3. Patient Assessment and Care Planning
   • Conduct comprehensive assessments of patients’ medical, psychosocial, and functional needs.
   • Develop, implement, and monitor individualized care plans in collaboration with patients, families, and healthcare providers.
4. Care Coordination:
   • Act as a liaison between patients, primary care providers, specialists, and community resources to ensure seamless care transitions.
   • Schedule and follow up on referrals, tests, and treatments to promote adherence to care plans.
5. Chronic Disease Management: 
   • Educate patients and caregivers on disease management, medication adherence, and lifestyle modifications.
   • Monitor clinical indicators (e.g. blood pressure, A1c levels) and provide timely interventions as needed.
6. Patient Advocacy:
   • Serve as an advocate for patients by addressing barriers to care, including transportation, insurance issues, and access to medications.
   • Promote health equity by connecting patients with culturally appropriate resources and services.
7. Data Tracking and Reporting:
   • Document all care coordination activities in the electronic medical record (EMR).
   • Analyze patient data to identify trends, monitor outcomes, and contribute to quality improvement initiatives.
8. Interdisciplinary Collaboration:
   • Participate in regular team meetings to discuss care plans, review patient progress, and identify opportunities for enhanced care delivery.
   • Provide input into program development and best practices for chronic care management.
9. Clinical Responsibilities
   • Respond promptly to critical labs or provider calls via designated communication channels.
   • Navigate and document patient care using EPM and EHR systems, ensuring compliance with workflow guidelines.
   • Facilitate communication and teamwork within integrated care teams, including MAs, Medical Support Partners, Care Coordinators, and providers.
   • Perform nursing care tasks under provider direction, including:
     1. Medication administration, wound care, EKGs, point-of-care testing, and procedural assistance.
     2. Medication reconciliation, refill management, and prior authorizations per protocols.
10. Patient Engagement
    • Collaborate in Medicare Annual Wellness Visits by pre-screening and scheduling eligible patients.
    • Support patient care by addressing medical inquiries, communicating lab results, and coordinating care plans.
11. Administrative Support
    • Oversee and assist with patient intake processes, including:
      1. Reviewing health histories and medications.
      2. Prioritizing new patient appointments based on clinical urgency.
      3. Retrieving medical records and facilitating PCP assignments.
      4. Provide support to MAs and act as a resource for clinical guidance.
12. Other:
    • Attend mandatory meetings.
    • The employee may be required to provide services to an individual who is not a patient of the health center when the provider is then asked, called upon, or undertakes at or near the location of an emergency to provide service to a non-health center patient in an emergency situation, or temporarily treat or assist in treating the non-health center patient.
      1. Maintain current licensure and CPR certification.

The above duties are not all inclusive and are not intended to limit or define the duties that may be assigned.

Physical Demands:

The physical demands described here are representative of those that are typically required to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

• The employee frequently communicates with employees and the public and must be able to exchange accurate information while performing patient care tasks and routine office tasks.
• The employee frequently retrieves and disseminates information using written materials and electronic devices.
• The employee frequently observes, receives and otherwise obtains information from all relevant sources and identifies information by categorizing, recognizing differences or similarities, and detecting changes in circumstances or events.
• The employee frequently utilizes medical equipment necessary to maintain medical and basic lab activities in an ambulatory care clinic.
• The employee frequently operates computers and other office productivity equipment.
• The employee occasionally remains in a stationary position while performing patient care tasks and routine office tasks.
• The employee frequently moves about the office; and positions self while performing patient care tasks and routine office duties such as accessing files and operating equipment.
• The employee frequently moves or positions objects weighing up to 25 pounds and occasionally up to 100 pounds while performing patient care tasks and routine office duties such as opening file drawers, moving patient files, etc.

Closing Date: Open until filled.

Pueblo Community Health Center is a tobacco-free workplace. EOE

Apply online at Pueblo Community Health Center

Qualifications