Chronic Care Management RN Coordinator

Qualifications: Diploma or degree from an accredited nursing school. One to two years experience in a clinic or hospital setting preferred. Knowledge of motivational interviewing, chronic care management, and quality initiatives within a primary care setting. Registered Nurse license from the State of Wisconsin. Current Basic Life Support (BLS) certification. Basic proficiency in Word processing and Excel; software proficiency covering a variety of health care / clinical record applications, Super User for at least 1 year, with experience in developing reports within the EMR. Work Hours: Full‑time (36 hours/week) RN available four days per week from 7:30 am to 5:00 pm. Job Summary: Responsible for serving patients within the Chronic Care Management Program. The RN acts as an extension of primary care providers’ care plans, supporting patients in successful self‑management of their chronic disease, optimizing health outcomes, and improving overall patient experience. The program’s goal is to re‑engage patients who have not actively been seeking care or managing their chronic condition. Duties include direct patient care, education, and indirect duties under the supervision of the Director of Clinic Nursing and Quality, and reviewing clinical records before clinic dates. Essential Job Functions and Responsibilities Performs patient screening assessment and provides nursing care in the clinic or procedure room, including interviewing the patient to obtain medical history and chief complaint, performing medication reconciliation, and obtaining vital signs. Develops and maintains care plans with patients in collaboration with PCP, pharmacy, and other key team members. Prepares the patient for exams and/or procedures, provides education related to planned procedures, and ensures necessary consents are obtained. Performs diagnostic testing, such as inhaler in‑check testing. Makes contacts to appropriate care areas to schedule patients for follow‑up tests and/or procedures. Performs routine maintenance and cleaning of clinic equipment as appropriate. Transfers patients between bed, chairs, and transfer devices. Positions patient/equipment, monitors vitals, changes linens as needed. Performs all required paperwork and communicates with patient care team members, patients, and families. Operates computer and communication devices. Prepares/sets up or removes ancillary equipment and retrieves or stores supplies as indicated. Provides patient care in urgent/emergent situations. Performs CPR on patients during code before arrival of additional team members. Provides education to clinical staff and providers on how to improve chronic care patients and outcomes within their practice on a routine basis. Collaborates on a routine basis with other entities involved in Chronic Care Management, such as pharmacy, diabetes education, respiratory therapy, care coordinators at hospital, etc. Collaborates with Director of Clinic Nursing on quality initiatives and assists in achieving goals with providers’ guidance. Adheres to Southwest Health’s value‑based behavior standards. Understands and adheres to Southwest Health compliance and HIPAA standards as they appear in the Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy. Performs other duties and responsibilities as requested or required. Benefits: A full benefit package is available for employees working 20 hours/week or greater, including Health, Dental, Vision, and Life insurance; long and short term disability; cell phone discount; flexible spending plan; paid time off; retirement plan with employer contribution; fitness membership discount; and use of exercise equipment at the facility. Equal Opportunity Employer. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr