RN - Hospital Care Management

The Center Nurse is a clinical care team member operating within a Value-Based Care model, which prioritizes patient health outcomes and long-term wellness. In this model, the Center Nurse supports the health of patients by utilizing standards, guidelines and pathways for care delivery to prevent complications before they occur. Our Center Nurses drive quality care through clinical assessments, chronic condition management, and collaborating with the care team to reduce avoidable hospitalizations. You will foster an engaging and welcoming environment through effective team communication and delegation, empowering everyone on the team to deliver the best care to our patients.

Our Center Nurses report to the Practice Manager.

Support patient assessment and prioritization for both walk-in and telephonic triage to ensure patients receive the right level of care and avoid unnecessary hospital visits.

Perform skilled nursing procedures including wound care and medication administration (including vaccines).

Provide comprehensive patient and caregiver education regarding chronic conditions and preventative care in person, over the phone, or in group settings.

Conduct medication reviews within nurse-led visits to ensure patient safety and adherence.

Conduct onsite testing (including point-of-care labs, EKGs, and specimen collection) and use patient data to identify and close gaps in preventative screenings, ensuring compliance with state scope of practice.

Review and act upon high-priority abnormal laboratory results in a timely manner to maintain patient safety and continuity of care.

Partner with providers and the interdisciplinary team to manage complex care plans and coordinate weekly transitions for patients moving from the hospital back to the clinic.

Delegates to medical assistants and phlebotomists as needed to support patient flow and efficiency.

Supports the coordination, integration, communication, and implementation of nursing practice and standard operating procedures.

Identifies barriers to optimal care, e.g. physical, cognitive, language, literacy, socioeconomic, cultural, and or behavioral.

Create a welcoming and engaging environment to meet the needs of our patients, communities, families and teams where they are.

Deliver an exceptional patient experience through service, responsiveness and respectful care.

Serve as a key clinical voice in daily care team meetings to align on patient priorities and clinic operations.

Serves as a support and resource for nursing, other clinical staff and providers.

Provides emergency care in accordance with organizational procedure.

Seeks, acquires and maintains current nursing knowledge and competence to fulfill responsibilities as a Center Nurse.

Maintains awareness of current patient centered, evidence-based practice and considers applicable research data to patient care delivery.

Active, Unrestricted Registered Nurse Licensure in the state that you reside

Fluent written and spoken English language skills.

Electronic Medical Record (EMR) experience

Ability to maintain patient confidentiality and process information in a confidential manner

Ability to collaborate and communicate with members of an interdisciplinary care team

Excellent computer skills with ability to read, interpret and analyze data from various computer systems

J-18808-Ljbffr Oak Street Health, part of CVS Health