What are the responsibilities and job description for the Nurse Patient Care Coordinator/Educator position at New Horizon Family Health Services?
NEW HORIZON FAMILY HEALTH SERVICES, INC.
POSITION DESCRIPTION
JOB TITLE: Nurse Patient Care Coordinator/Educator (NPCC/E)
DEPARTMENT: Clinical
SUPERVISOR: Charge Nurse with Supervision / Nursing and Clinical Support Services Director
STATUS: Non-Exempt
**IMPORTANT NOTE**
THIS DOCUMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT
JOB SUMMARY
The NPCC/E works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illness. This position supports improvements in health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. The NPCC/E will teach, counsel and monitor patients on issues relevant to their health. As a member of an interdisciplinary team, this position will consult with other health care team members to coordinate the provision of patient education, preventive care and disease management.
DUTIES PERFORMED
- 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.
New Horizon Family Health Services reserves the right to revise or change job duties and responsibilities as the need arises.
THIS DOCUMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT
REQUIREMENTS – Education, Experience and Licensure
Basic requirements:
- 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
Preferred requirements:
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
Benefits:
New Horizon Family Health Services offers a robust and comprehensive benefit package to full time employees. These choices/options include:
- Vacation plus holidays and sick leave
Optional Benefits which include:
- Medical (PEBA State Health Plan), Dental and Vision benefits
- Flexible Spending and Health Savings Accounts
- Voluntary Life Insurance
- Short Term Disability and Long Term Disability
- Optional contribution to a 403 (b) Retirement Plan, with up to 4% employer match after the first year of employment
- Continuing education courses through SC AHEC
Mission:
Our Mission is to provide quality, affordable, compassionate patient-centered health care to improve the health of the communities we serve. Our Vision is that our community will be one of the healthiest in the Nation. Superior patient care is the hallmark of NHFHS.
Community:
Greenville, South Carolina is the perfect place to live, work, and play. Greenville is surrounded by mountains, lakes, hiking & biking trails, as well as recreational activities including golf, tennis, water sports, cultural performances and more. Geographically located between Atlanta, GA and Charlotte, NC, with beaches just 3.5 to 4 hours away.
We are an Equal Opportunity employer.
