PCMH Nursing Coordinator

Position Summary

The PCMH Nurse Coordinator works in collaboration with the patient, family, providers, clinical support team and office staff and within the team structure, to ensure the provision of patient-centered, cost effective, high quality care. Patients under the care of the Coordinator will be supported by the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.

Essential Functions, Duties, and Responsibilities

• Identify patients within the team with anticipated high cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease
• Link patients with community resources to facilitate referrals and respond to social service needs
• Utilize referral protocols and agreements with subspecialists to meet patients’ needs and achieve goals and objectives in their plan of care
• Track and support patients when they obtain services outside the center such as the Emergency Department, hospitals and other subspecialists
• Follow up with patients within a few days of an emergency room visit or hospital discharge
• In collaboration with providers, communicate test results and care plans with patients and families
• Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical team
• Provide relevant self-management support, including patient education, for patients with chronic illnesses as identified by clinical teams
• In collaboration with provider, provide skilled nursing services appropriate to the scope of a community health center including provision of wound care
• In collaboration with the behavioral health team and provider, coordinate the clinical preparation and care for Medication Assisted Treatment for patients with a Substance Use Disorder
• Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals
• In collaboration with administrative staff and enabling services, assist patients with the process of determining eligibility and to obtain and maintain free pharmaceuticals through the Patient Assistance Program
• Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns
• Address patient and family concerns and initiate corrective action. Bring identified issues to the attention of supervisor
• Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
• Triage patients who present to the health center and who require evaluation for routine, acute, emergent, or urgent care
• Handle phone calls from patients seeking medical information and/or medical attention.
• Schedule appointments as the patient’s condition requires answer questions, and provide limited health education
• Furnish medical advice per approved triage reference books
• Process medication refill requests
• Correctly assess stat triage patient’s vital signs and charts them accurately
• Assist the office staff to appropriately identify the patient’s acute needs and direct that patient to receive the care required
• Assist in transfers to hospital
• Assist in the collection of data and preparation of reports and registries for review by the QA/PI Committee
• Ensure timely documentation in Electronic Health Records
• Participate in Performance Improvement/Continuous Quality Improvement activities
• Adhere to policies/safety practices established by the Zufall Health Center
• Maintain confidentiality of all patient information
• Work effectively with other members of the health care team to optimize interventions.
• Serve as subject matter expert in POS labs, duties of Medical Assistant, Clinical Competencies, Standing orders
• Assess annual competencies for the Medical Assisting Staff
• Oversee orientation of new Medical Assistants, assigning them to preceptors for orientation, tracking orientation progress through the use of the Medical Assistant Orientation checklist, provide feedback to Site Manager as necessary
• Work with the CMA’s, providers, DON and clinical pharmacist to maintain pharmacy stock, order medications, evaluate ordering history and make recommendations for changes to medication formulary to meet the needs of the providers and site
• In collaboration with DON, work with other sites as necessary to assist with MA training and Competency Assessment
• Maintain/rotate the VFC/317 vaccine stock to prevent vaccines from expiring or running out. Order vaccines in a timely manner. Assist with maintaining the registry. Serve as subject matter expert on NJIIS and VFC/317 for both children and adults
• Performs other duties as assigned by Director of Nursing and Chief Medical Officer
• Assume duties of Director of Nursing as assigned in the absence of the Director of Nursing

Knowledge, Skills and Abilities

• Possess thorough knowledge of practical nursing theory, standard practices, rules, and regulations related to nursing, knowledge of anatomy and physiology, and knowledge of aseptic technique
• Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals
• Excellent verbal and written communication skills
• Bilingual in Spanish/English
• Ability to anticipate primary care provider’s needs
• Excellent computer skills, experience with electronic medical records a plus
• Ability to interact with patients, staff and outside agencies appropriately
• Ability to follow instructions, given either orally or in writing
• Ability to work independently or with little supervision
• Excellent organizational skills such as problem solving, decision making, priority setting, and work delegation
• Ability to complete assignments in a timely manner
• Ability to work as a team member
• Ability to maintain HIPAA compliance, corporate compliance and client confidentiality

Education, Training and Experience

• Licensed Practical Nurse or Registered Nurse training
• Current license Registered Nurse in the State of New Jersey
• One to two years’ experience in a clinical setting, including direct patient care and triage experience
• Prior experience in an ambulatory care or outpatient clinic setting and case management experience preferred