Job Summary

This position is responsible for the coordination of medical care in the transitional and outpatient care setting provided to high risk patients of Skagit Regional Health. This position will partner with physicians. This position also provides systematic identification of gaps of care, care management needs of high risk patients identified by various health plans or employer groups, to support improving care delivery to these patients for the purposes of enhancing quality of care and the overall organizational quality performance objectives. Is the key educator for patients with complex medical conditions and is able to design solutions that assist patients attain and maintain their maximum health.

Essential Functions

• Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients.
• Educates patients regarding test results and medical conditions, explaining medical terms and procedures and determines barriers to successful medical outcomes are for each patient.
• Solves problems, coordinates the chronic disease management for patients with complex medical conditions.
• Maintains communication with all the clinicians involved in the patient’s care.
• Maintains a close working relationship with all of their patients’ primary care providers.
• Works well in multidisciplinary teams.
• Coordinates and assists patients in scheduling acute, specialty, or routine care appointments, including referrals.
• Demonstrates proficiency in application of clinical knowledge as it applies to the specific clinic setting.
• Considers cultural, spiritual, and psychosocial factors that affect patient perception of and adherence to health care plans when interacting with patients, families, support systems, and the community.
• Utilizes critical thinking and assessment skills to follow provider approved protocols.
• Contacts pharmacy for medication refills for patients as needed.
• Maintains a working knowledge of medication frequently utilized, researching any medication not familiar with.
• Develops a familiarization with brand/generic medication names.
• Maintains familiarity with all forms and paperwork utilized throughout the clinic.
• Participates in the advancement of professional nursing practice through continuing education and self-development; develops and maintains professional credibility.
• Demonstrates professional nursing leadership and contributes to a smooth work flow by assisting team members as needed.
• Assists other providers as needed for the best patient flow.
• Responds to codes within the assigned facility if assigned to code team.
• Collaborates with department Practice Manager and Clinical Supervisor to ensure new team members receive appropriate orientation and reports on trainee performance.
• Serves as clinical resource to department staff; contributes to the professional growth and development of other clinical staff.

Education

Graduate of an accredited RN program required. BSN preferred.

Experience/Training

Minimum one (1) year previous nursing experience in a clinic or acute care setting required; experience specific to departmental specialty strongly desired. Experience with care coordination, high risk care management or case management preferred. Patient education experience required. Experience analyzing clinical data to identify trends that indicate improvement is needed is preferred. A background in quality management is preferred.

License/Certifications

Current WA State RN License required. Current American Heart Association Healthcare Provider BLS required. Current certification from one of these organizations, American Academy of Ambulatory Care Nursing (CCTM), National Academy of Certified Care Managers (CM) or the Commission for Case Manager Certification (CCM) or Health & wellbeing coach training (DHWCT) is preferred. Successful candidates are expected to obtain one of these certifications within 36 months of employment.

Other Skills

Excellent interpersonal communication skills; both written and verbal. Skills in motivational interviewing required. Strong organizational skills and technical proficiency. Must have the ability to work independently with minimal supervision and use critical thinking skills to problem solve. Proficient in the use of Electronic Health Record systems, Microsoft Office suite and other clinical applications. Bilingual Spanish/English preferred.

Physical Demands and Work Environment

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. While performing the duties of this job, the employee is regularly required to talk and hear. This position is very active and requires standing, walking, bending, kneeling, stooping, crouching, crawling, and climbing all day. The employee must frequently lift or move objects and patients weighing over 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus.

Benefits

Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.