CCAP Mission Statement - To empower all people and communities, challenged by poverty as well as social and cultural barriers, through advocacy, education, and access to high quality health and human services.

SCOPE OF ASSESSMENT AND PATIENT MANAGEMENT:

The Nurse Care Manager will have the opportunity to work on a multidisciplinary healthcare team in a community health clinic care setting. The Nurse Care Manager will be part of a program charged with working within the patient care medical home and administering health care in a new and innovative way. The Nurse Care Manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education and self-management support to patients with chronic health conditions, such as coronary artery disease and depression.

WORK SCHEDULE DEMANDS

The position is full-time, 35-40 hours per week, may vary when specified by the program director.
Occasional unscheduled overtime may be required.
May be required to work in any Family Health Services’ locations at the discretion of the Director of Quality Improvement and Compliance.

COMMUNICATION SKILLS

Interpreting technical medical terminology daily.
Use all available methods of communicating with patients, such as interpreters, individual counseling, group discussions, written materials, and visual aids.
Communicating and identifying cultural, social and economic character of the patient population served.
Ability to communicate with staff and providers tactfully and effectively.

CONFIDENTIALITY OF INFORMATION

Full access to client's medical record and some access to financial/statistical material.
Maintains client confidentiality at all levels of interaction in accordance with State and Federal Laws and CCAP policies and procedures.

KEY RESPONSIBILITIES

Works under the direct supervision of the Nursing Director.
Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed.
Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
Assure that preventive screening tests are up to date.
Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules.
Promote compliance with chronic care plan.
Coordinate care and communicate with multiple providers, both within and external to the practice.
Review test results and track outcomes.
Review patient compliance issues.
Work one-on-one with patients.
Arrange group visits.
Leverage EMR/chronic disease registry reporting to prioritize patient follow-up.
Identify and utilize cultural and community resources.
Develop quarterly reports on service volume, distribution of patients by plan, and types of services provided.
Ensure open and effective communication regarding patient status with physicians and office staff.
Act as liaison to hospital, long-term care and specialists.
Attend required training and collaboration sessions as scheduled.
Train staff on motivational interviewing.
Interact and coordinate with insurance companies’ and other external agencies’ Case and Disease Management staff, when applicable in caring for the patients within the Patient Centered Medical Home.

REQUIRED QUALIFICATIONS

Licensed Registered Nurse from an accredited school.
Three (3) to five (5) years’ experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
Current BLS certification.
Experience working with patients regarding their care coordination and disease management/education is preferred. Perform quality work within deadlines with or without direct supervision.
Share best practices among all teams, serve as a medical home advocate, mentor and lead by example to support a positive work environment, and encourage other staff to do the same.
Represent the practice in a positive manner to all patients and all applicable external clients.

PHYSICAL EFFORT / ENVIRONMENT

Frequent use of phone, writing, typing and doing vital signs and verbal communication. The tasks of this position are normally performed in a physician office setting. Mobility is required to attend meetings and give presentations. The ability to travel to various locations in the state, typically via car is required. Regular lifting of up to 25 pounds is expected. Must be able to maintain a good attendance record. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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