- 20-Apr-2017 to 19-Jun-2017 (EST)
- Gaithersburg, MD, USA
- Full Time
CCI Health & Wellness Services is a group practice empowering patients to partner with staff for an unparalleled healthcare experience. Through integrated teams in a learning environment, we deliver high quality affordable care to every patient during all stages of life.
The CCI Health & Wellness Registered Nurse Care Coordinator (RNCC), under the direction of the Nursing Director, will use his/her nursing experience and clinical knowledge to collaborate with designated patient populations in managing their healthcare needs to improve health outcomes. This includes but is not limited to, conducting care management processes as part of the Patient Centered Medical Home, interacting with care teams, participating in activities that support the Care Management Program at CCI, and engaging in the delivery of quality patient care.
KEY FUNCTIONS/ RESPONSIBILITIES:
- Demonstrate and apply knowledge of the philosophy and principles of comprehensive, community based, patient and family-centered, and culturally sensitive care.
- Assist with and promote the identification of designated patient populations with special and/or complex health care needs
- Perform, facilitate and/or coordinate pre-visit activities to identify prioritize, anticipate, and manage potential health care needs before the visit.
- Collect patient and population data using appropriate evidence-based assessment techniques, analyze to determine nursing diagnoses for health promotion or maintenance, and develop/evaluate a plan of care in collaboration with the patient, his or her support network and the multidisciplinary care team.
- Perform evidence-based health coaching to facilitate self-management skills, treatment plan management and adherence.
- Assist with data collection, preparation, and submission of reports as required.
- Serve as the contact point, advocate and informational resource for family and community partners.
- Educate, counsel, and support patient and support system to facilitate self-management and health promotion behaviors through one-on one encounters or group visits.
- Cultivate and support transitions of care through timely communication, inquiry, follow up and integration of information.
- Collect data to measure quality, identify, test, refine and implement practice improvements
- Utilize in-person or telephonic interpreters and provide verbal and written information on identified health issues in the patient's preferred language.
- Attend interdisciplinary and multidisciplinary meetings and collaborate in the provision of population-specific training.
- Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; and participating in professional societies.
- Work cooperatively with staff, providers, and site leadership triad (Health Center Medical Director, Nursing Manager, and Health Center Manager) and Administration.
- Work within the policies and procedures of CCI Health & Wellness Services, Inc.
- Other duties as assigned
SPECIFIC JOB SKILLS:
- Ability to implement, monitor, and manage requirements within the primary care setting.
- Professional nursing skills are required and include but are not limited to the following:
- Critical thinking and assessment.
- Problem analysis and proposal of resolutions based upon available resources.
- Multidisciplinary team collaboration, strong communication skills, and leadership abilities
- Physical abilities:
- Standing for long periods of time.
- Occasional bending and stooping.
- Occassional lifting, pushing and/or moving of up to 25 pounds.
- Operating a computer including keyboard, multi-line phone.
- Working in excess of 8 hours per day or 40 hours/week as needed.
- Bachelor of Science in Nursing.
- State of Maryland Registered Nurse License with minimum of 1 year of experience
- Written and oral fluency in English.
- Experience in an ambulatory care setting, preferably a community health center serving culturally diverse and underserved patient populations.