Nurse Care Coordinator

Registered Nurse

Provides professional nursing care for patients of Mountain Laurel Medical Center in the Oakland and Westernport locations. This position is also responsible for ensuring that patients of MLMC have medical information, education and resources available to them and providing assistance and assurance of continuity of care provided by MLMC or other healthcare providers. The RN will assist the patient in accessing other local, state and national programs and support systems and assist the patient in proactively managing acute and chronic disease issues through education and prevention activities both face-to-face and via telephone. This position must encompass a patient centered mindset that is quality driven.

Essential Duties and Responsibilities:

• Through both triage and formal care planning, the NCC provides medical and disease specific education to patients.
• Works in conjunction with the Community Health Worker, helps patients identify and overcome barriers to care. Helps establish health goals and coaches/mentors patients to achieve goals of healthier outcomes. Establishes patient relationships that allow for care coordination including contact with the patient on a regular basis by face-to-face meetings or telephone.
• Monitors inpatient admission and Emergency Department utilization and coordinates the transition of care with all local hospitals of any of MLMC patients, including follow-up appointments and identifying potential barriers and/or transition of care needs.
• Provides disease specific education to MLMC patients which may include providing diabetic education through MLMC's accredited DSMES program.
• Assists patients with glucose monitoring which may include training patients on appropriate use of glucometers or CGM devices.
• Downloads CGM device reports and manually uploads the report into the patient's electronic medical record.
• Assists all providers with the Medicare Annual Wellness Visit by completing screeners (fall risk, Mini Mental Status Examination, geriatric depression), summarizing care history, and identifying gaps in care.
• Completes provider referrals to registered dietician, cardiac/pulmonary rehab, home health services, Hospice, and external DSMES programs.
• Monitors and ensures accuracy of recording on patients electronic medical records; documents all activities as required by professional licensure; maintains patient's electronic files.
• Provides direct service to patients in the conduct of various clinical procedures within the approved scope of nursing licensure including administering immunizations.
• Participates in the research and development of assistance programs for uninsured patients.
• Provides direct patient care and assists providers with examinations, office procedures, EKG procedure, and minor surgical procedures, CLIA tests, allergy injections, immunizations and other processes related to direct patient care as needed.
• Monitors medical conditions of patients and reports changes to appropriate clinical personnel.
• Maintains a safe, comfortable, and therapeutic environment for patients/families.
• Facilitates prescription medication refills as directed by providers including medication assistance programs. Documents all correspondence in the electronic medical record, inclusive of dispensing pharmaceutical medication samples as directed by the provider.
• Inspects area daily for compliance with policies, procedures, regulations, and standards; ensures an adequate stock of medical supplies and proper functioning of equipment.
• Facilitates all patients' care telephone calls; reviews tests/lab results with provider and coordinates results/resolutions as directed.
• Triages incoming patient calls, answers questions when able; connects to providers when needed.
• Perform Medical Assistant duties when needed including vitals, chief complaint and patient rooming.
• Monitors status of labs; ensuring that results are received in the proper time.
• Provides excellent patient centered customer service while being friendly and courteous to all employees and patients; can handle multiple tasks at once and has the ability to compassionately and empathetically care for patients.
• Comply with the established clinical policies and procedures that address established standards of medical care and ensure continuity of care that focuses on the health care needs of MLMC patients.
• Upholds the Code of Ethics and mission of Mountain Laurel Medical Center in a manner consistent with the core values of respect, accountability, integrity, teamwork, continuous improvement, and patient-focused.
• Other duties assigned by the supervisor.

Requirements:

Qualifications:

The successful candidate will possess and be able to demonstrate competencies within the approved scope of practice standards. In addition, the RN must have a working knowledge and understanding of all internal workings of primary care outpatient clinic and have the ability to direct and motivate other clinical support staff in their respective roles. Will have a demonstrated work record showing good attendance, punctuality, dependability and the ability to work as a member of a team with supervisors, providers and other co-workers and to work with the public and medical community at large in an appropriate professional manner.

Education and Experience:

Must be a Registered Nurse (RN); BSN preferred. Experience and knowledge with EMR's, quality assurance, ambulatory primary health care, DSME, and care coordination processes are a plus.

Computer Literacy:

Knowledge of basic computer software and the willingness and ability to learn EMR software.

Work Record:

A demonstrated work record showing good attendance, punctuality, dependability and the ability to work well with supervisors and coworkers as part of a team effort is essential. A medical office setting is an environment that requires the ability to relate to all types of people while always maintaining a professional demeanor.

Language Skills:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals is essential. Ability to write routine reports and correspondence, and the ability to speak effectively to patients, co-workers and the public at large is of the utmost importance.

Mathematical Skills:

Must have the ability to calculate figures and amounts such as, proportions and percentages along with mathematical accuracy and attention to detail are essential skills for this position.

Reasoning Ability:

Must be able to demonstrate the ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Team Work:

An essential element is the ability to work and interact effectively and positively with other staff members to build and enhance teamwork in a patient centered team based model of care and in the overall MLMC organization; team engagement is a must to be successful in this position.

Sensitivity to Confidentiality:

Must be able to demonstrate a high level of confidentiality and the ability to manage all company information accordingly.

Sensitivity to the Needs of Special Populations:

Must be able to demonstrate the ability to understand and respond appropriately, effectively and sensitively to special population groups served by MLMC. Special population groups include those defined by race, ethnicity, language, age, sex, sexual orientation, economic standing, disability, religion, etc.

Understanding of HealthCare laws and Regulations:

Must have the ability to follow HIPAA guidelines as well as an understanding of policies and procedures regarding medical records put in place by the Federal Government.

Additional Skills:

Must have strong interpersonal communication skills, including the ability to respectfully interface with a socioeconomically and culturally diverse population and must also demonstrate a detail-oriented work ethic, and the ability to adapt quickly with a dynamic work environment. Clinic management responsibilities are critical and must be demonstrated.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to drive, sit, handle papers, type and operate computer equipment; reach with hands and arms; talk, see and hear.

Work Environment:

Work is performed in a typical business office environment with the ability to work via telephonically on a manager approved basis. Some local trips by automobile may be required to other facilities (i.e., Post Office, office supplies, etc.). Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

Salary Description $27.47 to $38.46 Hourly