REGISTERED NURSE SPECIALIST

Registered Nurse SpecialistThe incumbent works in the Health Care for the Homeless Program within the scope of Agency protocols and State and Federal guidelines. The incumbent works as part of the medical home team and is expected to perform functions requiring independent judgement and licensure as a Registered Nurse and provide services within those guidelines. The Registered Nurse Specialist provides ongoing outreach and clinical care coordination services to primary care clients in order to meet their comprehensive health care needs and to promote high-quality, cost-effective outcomes. Manage and coordinate medical and preventive services for clients based on need and evidence-based guidelines. Develop and monitor individual client care plans in collaboration with client and medical home team. Identify and increase client's knowledge regarding their medical and preventive treatment. Utilize nursing skills of interview, observation, and assessment to determine the medical needs of the client and motivate the client to self-management. Use the nursing process to plan for ongoing assessment of risk factors and services. Educate and counsel clients in basic health principals and risk behaviors, including, but not limited to, management and prevention of chronic diseases and their complications, communicable disease control, maternal health, family planning, nutrition, and safety with emphasis on prevention. Provide case management to clients in need of nursing intervention and make appropriate referrals. Provide direct services to clients including immunization, administration of ordered medications, tuberculin testing, vital signs and other testing or services which fall within the nursing practice. Assist providers with patient care plans as needed. Ensure a safe and healthy environment by adhering to OSHA guidelines for the prevention of exposure to blood borne pathogens, utilizing universal precautions. Prepare for and handle emergencies and treat according to standing orders as needed. Prepare for, facilitate and participate in daily huddles Actively identify eligible clients for care coordination services through running reports in NextGen, monitoring referrals from medical home team, conducting chart reviews and monitoring primary care clinics. Monitor the benchmarks for the client's on-going medical and treatment plan such as compliance with labs, medication, and primary and specialty referral appointments. Monitor clients for appointments and services that are overdue and follow up as appropriate. Monitor and follow up on reports of ER and hospital visits. Monitor the biometric measures of the client's disease process. Evaluate the outcomes of patients with chronic diseases. Enter health information and other pertinent data into NextGen system, including plan of care. Coordinate Pre-Operative Clearance and Post-Operative needs. Work with referral coordinators and patients to ensure follow-up on specialty referrals. Document accurately and on time using agency forms, designated software programs, and established policies and procedures within the Agency and/or supervisor established timeframes. Promptly report unusual clinic activities to supervisor or center manager. Maintain confidentiality of all records, client interactions, and services according to HIPAA privacy policies. Communicate with immediate supervisor and medical home team. Participate in quality improvement activities including chart review, in-service programs, and staff meetings. Complies with core performance standards. Complete training to promote professional growth. Schedule time off in advance and collaborate with supervisor to ensure duties are covered when absent. Attend and actively participate in Nursing Action Team, clinic, QI, and/or other agency and community teams and meetings as assigned.