JOB SUMMARY

• Assess cognitive/verbal skills and identify barriers to accessing healthcare.
• Provide individual and family educational interventions including self-management goal-setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease.
• Perform individualized assessment of a patient’s educational needs and provide tools to aid in managing their disease(s) effectively.
• Provide individual counseling on office procedures, eligibility for programs/services, importance of a primary care medical home and other health issues.
• Monitor patients for changes in health status after initiation of a new medication, a hospitalization or recent decline in function.
• Follow-up with patients when barriers to referrals are identified.
• Monitor lifestyle factors affecting health – such as tobacco use, substance abuse, nutrition and physical activity – and assist the patient with goal-setting to achieve behavioral change.
• Document assessments, education, goals, outcomes and updates in the patient’s EHR for review by their practitioner.
• Participate in staff meetings focused on coordinating patient care within an interdisciplinary team, keeping the team updated on a patient’s condition and circumstances.
• Triage and facilitate response to urgent telephone calls, requests or visits from assigned patients.
• Assist with arranging supportive services as needed.
• Perform an intake assessment which includes obtaining and reviewing prior medical records and documenting a complete medical history (Ryan White).
• Understands orders, laboratory testing, immunizations, TB skin testing and referrals for preventive health needs as indicated per disease management protocols.
• Provide counseling and facilitate screening for HIV, other STDs and Hepatitis as indicated.
• Teach individual and/or group classes covering topics which build skills in self-management of one or more chronic diseases.
• Assist in the development and maintenance of a library of educational resources including written materials and web/online based for related health issues.
• Serve as a consultant to the rest of the health care team for educational resources, reviewing them for language, cultural competency and reading level.
• Understands the purpose of and has a working knowledge of Patient Centered Medical Home concepts.
• Work with the clinical team to complete patient work-up, helping to maintain patient flow.
• Assist the clinical team by completing patient medication reconciliation, diabetic foot exams, referral/lab tracking and other provider orders.
• Tracking: Works as necessary with Nursing Staff team members to track required information supporting Patient Centered Medical Home guidelines.

• Complete Nursing Orientation and documentation.
• Ryan White NPCC/E: complete and document a minimum of 50 face-to-face patient encounters each month.
• Chronic Disease NPCC/E: complete and document a minimum of 50 face-to-face patient encounters each month.
• Health Care for the Homeless NPCC/E: complete and document a minimum of 50 face-to-face patient encounters each month.
• Provide an activity report monthly within 5 working days of the end of the month.
• Must hold all patient Protected Health Information (PHI), other patient personal information and agency information in confidence, in accordance with the attached Employee Confidentiality Statement.
• Actively participate in and comply with all aspects of the NHFHS Corporate Compliance Program, follow the Program Code of Conduct and obey all relevant laws, statutes, regulations and requirements applicable to Medicaid, Medicare and other State and Federal healthcare programs.
• Participates in CQI, other internal committees, special projects/observances or activities that promote improvements in organizational performance and/or advance the mission, goals and objectives of New Horizon Family Health Services.
• Observes schedule for work, lunch and breaks.
• Completes other job duties/tasks as assigned by the Practice / Program Manager, Supervising Charge Nurse, DNCSS, CMO or CEO.

• Associates or Bachelors Degree in Nursing and 3 years work experience related to chronic disease management and licensure as an RN in South Carolina or, Practical Nursing Degree, 5 years work experience related to chronic disease management and licensure as an LPN in South Carolina
• Experienced in patient education and/or chronic disease management
• Must have a working knowledge of computer programs and professional construction of emails
• Must demonstrate
• legible handwriting
• excellent spelling
• speaking clearly and grammatically correct
• the ability to accept responsibility as indicated
• being a motivated and enthusiastic learner
• a courteous and tactful manner
• the ability to work under stress and work well with others
• following NHFHS policies and procedures regarding personal visits, cell phone usage and clocking-in on time according to your assigned shift

• BSN Degree in Nursing

• Post graduate training in care management such as a Certificate in Guided Care Nursing or ANCC certification in Case Management Nursing

• Experience working in clinical out-patient settings
• Experience working with diverse population groups
• Content knowledge and expertise in program-specific field

Knowledge and Skills

• Familiarity with local community resources for patients with chronic disease
• Knowledge of patient teaching, health promotion and disease prevention methods related to routine health care and those designed to address the needs of patients with chronic, disabling health conditions
• Understands the purpose of and has a working knowledge of PCMH concepts
• Ability to maintain effective work relationships
• Ability to make accurate professional judgments
• Ability to develop a collaborative therapeutic alliance with individuals