Care Team Nurse

Job Duties and Responsibilities:

• Work as part of the clinical nursing team to provide a full range of nursing services, including patient assessment, phone advice, case management, care team coordination, provide patient education.
• Review provider/clinician laboratory results on a daily basis, identifying and communicating common items to patients or provider per organizational protocol.
• Review provider/clinician diagnostic imaging reports received from outside agencies and communicate to patients or provider per organizational protocol.
• Refill medications for care team patient panels per established Nursing Protocols.
• Monitor care team patient panels referral status, ensuring documentation is complete, patient compliance or barriers are addressed, and referral completion is documented.
• Work to resolve telephone encounters within 72 business hours of receipt.
• Monitor support team and nurse schedule for appropriate appointment types and cycle times.
• Notify patients of test results and follow up plan per protocol or as directed by provider/clinician.
• Monitor provider's schedules in the care team for available daily access for each care team provider/clinician and that each appointment is appropriate for each individual provider's scope of services.
• Monitor population management activities by support staff, ensuring documentation is complete and interventions are identified in the patient's health record.
• Ensure effective management of the vaccine/immunization programs.
• Develop care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize unnecessary hospital inpatient and ER utilization.
• Utilize behavioral strategies, such as motivational interviewing, to assist patients in adopting healthy behaviors, improving self-care, managing chronic disease, and utilizing in-house resource.
• Assist patients in problem-solving issues related to the health care system, financial and psychosocial barriers.
• Provide ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of follow-up care.
• Communicate/affirm patient needs, plan of care, and changes in status with the patient's PCP, team, and the patient/family.
• Manage care coordination systems for referrals, ordered test completion, and receipt of report from outside providers.
• Supervises and supports integrative behavioral health services.
• Participate in care team meetings to evaluate outcomes of care with the care team.
• Provide leadership to care team support staff.
• Model professionalism and excellent customer service standards.
• Monitoring of Crash cart/AED.
• Other duties as assigned.

Education/Licensing/Training:

• High School Diploma or Equivalent.
• Valid RN or LVN California License in good standing with the California Board of Nursing.
• CPR Certification.

Knowledge, Skills and Experience:

• Ability to read, write, and communicate in the English language.
• Broad knowledge of principles and practices, care coordination or case management.
• Must possess excellent time management, organizational, and work planning skills.
• Knowledge of personnel management principles.
• Knowledge of health care regulations and guidelines.
• Demonstrated experience in a healthcare, mental health, or social work related field, or any satisfactory combination of experience and training which demonstrates the knowledge, skills and abilities to perform the above duties.

Medical, Dental and Vision Insurance 401(k) with matching Generous Paid Time Off, Personal Day, and Holiday packages Flexible Spending Account Plan Employee Assistance Program Life/ADD insurance policy Long Term Disability Insurance Compensation: $80,000.00 to $133,120.00 per year, depending on experience and credentials