November 27, 2018
December 31, 2018
The RN coordinates screening and provides care management to empaneled patients with identified complex care needs, assesses patient needs, and develops patient-centered comprehensive care plans. The RN is responsible for communicating needs and plans with multidisciplinary team, including primary care providers and behavioral health and provides guidance and leadership to other team members to ensures that patients receive the best possible care.
- Provide ongoing care management for patients identified as medium- and high-risk via:
- Comprehensive risk assessments.
- Integrated patient care plans focusing on disease self-management.
- Ongoing clinical assessment, monitoring and contact.
- Works closely with LPN Care Managers and Case Managers around specific care management tasks and responsibilities.
- Update providers on status of care plans, patient goals, and progress.
- Communicate with Behavioral Health, as appropriate.
- Promote patient health and prevention of secondary disease complications by providing education, counseling, and support about healthy lifestyle changes and specific disease management topics. This is frequently accomplished via motivational interviewing techniques.
- Manage care transitions, particularly from acute inpatient and emergency department settings, back into the medical home.
- Preform medication review, reconciliation, and coordination.
- Participate in care team huddles and meetings.
- Oversee implementation of policies and procedures regarding delivery of patient care applying infection control and safety standards.
- Maintain current knowledge of regulatory agency requirements of compliance and ensure that those standards are practice in the clinic.
- Other duties of assigned.
Essential Job Functions and Skills
- Stress Management, motivational interviewing skills
- Competency in Microsoft Office products and Electronic Health Record (EHR)
- Strong interpersonal/communication skills
- RN-Active State of Illinois License Required
- Bachelor’s Degree in nursing preferred.
- 3-5 years of nursing total experience preferred
- Bilingual in Spanish/English or Polish/English required
Benefits include PTO, Health/Dental/Vision Insurance, Short-term and Long-term Disability Coverage, Life/AD&D, 403(b), paid holidays.