Care Plan-RN na Family Circle of Care

Position Summary
The Care Plan Nurse – RN serves as a key advocate and care coordinator for patients within the Patient-Centered Medical Home (PCMH). This role provides comprehensive support across the continuum of care, focusing on disease prevention, chronic disease management, patient education, and improving overall health outcomes.

Key Responsibilities

• Collaborate with healthcare team members to develop, implement, and evaluate patient care plans.

• Direct and assist the primary care team in addressing clinical, health, and psychosocial needs.

• Coordinate patient education, appointments, and referrals, including nutritional and health visits.

• Identify patients for care management, assess care requirements, and intervene as needed.

• Document patient progress and education in the Electronic Health Record (EHR).

• Provide patient education on chronic conditions, medication management, and preventative care.

• Monitor quality improvement measures and participate in Payer Incentive Programs.

• Maintain compliance with federal, state, and programmatic regulations.

• Support quality improvement initiatives and PCMH activities.

• Act as a liaison for Family Circle of Care and community resources.

• Provide coverage for clinic duties or telephone triage, as assigned.

Patient-Centered Responsibilities

• Monitor patient comfort, safety, and clinical needs.

• Conduct assessments, obtain vital signs, and record nursing histories.

• Notify providers of changes in patient conditions and responses to treatment.

• Encourage patient engagement in their care through self-management education.

Supervisory Responsibilities

• Provide guidance and technical expertise to clinical staff (LVNs, MAs, CCMAs).

• Assist the Quality Improvement Director in training, performance appraisal, and problem resolution.

Qualifications

• Education: Bachelor of Science in Nursing required.

• Experience: At least 1 year of nursing experience in a clinical or hospital setting preferred.

• Licensure: Current RN license (or GN permit) in the state of Texas. Must maintain licensure, CEUs, and certifications as required.

• Certifications: Current BCLS Healthcare Provider Card (renewed every 2 years).

• Technical Skills: Proficiency in Microsoft Word, Excel, and EHR systems; EPIC experience preferred.

• Equipment: Experience with point-of-care testing equipment (e.g., glucose meters, BP monitors).

Core Competencies

• Strong communication and patient advocacy skills.

• Ability to lead and collaborate within a team environment.

• Demonstrated knowledge of chronic disease management and preventative care.

• Commitment to ethical standards, diversity, and cultural sensitivity.

• Strong organizational and problem-solving abilities.

Why Join Family Circle of Care?

At Family Circle of Care, you’ll be part of a growing healthcare organization recognized for its leadership in patient-centered care. We are dedicated to innovation in chronic disease management, preventative health, and community wellness. Our team is mission-driven, collaborative, and passionate about making a difference, giving you the opportunity to work in a supportive environment where your skills and compassion truly impact patients’ lives.