JOIN OUR TEAM!Reports To: Director of Physicians Clinic, Clinic Nurse Coordinator & Vice President of Patient ServicesStatus: 64-72 hours per two week pay periodShift: 8:00 am - 5:30 pmJob Schedule: Part-TimeWeekly Hours: 32-36 hoursPay: HRMC offers a competitive salary and benefits package.Statement of PurposeThe Chronic Care Nurse- plans, organizes, and coordinates the nursing care plan for high acuity patients. The primary responsibility of the Chronic Care Nurse is to manage care for patients of the clinic through promoting effective education, self-management support, and timely healthcare delivery. This position assists with the care coordination of complex patients with internal and external resources, as an extension of the clinic provider practices. The Chronic Care Nurse completes these responsibilities in a manner that is consistent with the mission, vision, values, goals and objectives of Huron Regional Medical Center. This registered nurse will demonstrate performance consistent with professional standards of practice, care, and the Nurse Practice Act.Demonstrates the mission of HRMC by demonstrating the Core Values:•Be Accessible - determined to provide local interventional healthcare for the community.•Be Helpful - always help each other while caring for others.•Be Knowledgeable - knowledge applied thoughtfully to others.Essential Job Functions
- Developing and administering patient care plans
- Active participation as a member of the clinical care teams to assist with duties such as Annual Wellness Visits and Nursing Home patient care coordination
- Optimal care coordination with hospital, ER, consulting physicians and community resources as necessary
- Develop and manage a workflow to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by specialty physicians or by another health care provider
- After visit summary review with patients whenever appropriate
- Educating the patients about self-management tasks they can undertake to gain greater control of their health status
- Manage patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner
- Work with social services and other health care professionals to identify, plan for, and provide an appropriate follow-up plan of care for patients. Communicate this plan of care to patient's families, medical providers, hospital staff when appropriate, community support, other agencies and departments
- Occasionally assist with coverage on the clinic care teams - based on staffing needs
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
Other Job Duties
- Develop relationships with patients as an integral member of the care team
- Provide follow-up contact with patients as indicated to ensure compliance with recommendations - medications, lab/x-ray, specialists visits, PCP visits, dieticians, CDE, etc.
- Review periodic status reports, dashboard results, and other information related to clinical care delivery
- Communicate with physician groups regarding statistical and financial impact of care delivery. Serve as an education resource for clinic care team on changing payor requirements
- Responsible for being available to provide telephone advice per protocol, handle urgent and emergent calls
- Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence
- Determine and complete appropriate referrals
- Responsible for working with patient and patient's care team to coordinate change readiness, needs assessment and develop and individualized treatment care plan
- Collaborate with the patient, physician and other care team members in assessing the patient's progress toward individual healthcare goals
- Assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept appointments
- Oversee the development, procurement and adoption of patient self-management educational resources used by the primary clinical teams
- Participate in regular team meetings and peer review activities. Participate in department and organization committees as applicable. Promote collaborative teamwork and work with peers in a team situation. Collaborate with payer Case Managers for additional services when appropriate
- Other duties as assigned
Requirements
- Must be a graduate of an accredited program
- Licensed as a Registered Nurse by the state of South Dakota required
- CPR Certified
- Bachelor's degree in nursing preferred
- A minimum of 3 years of nursing experience required. Five or more years of nursing experience preferred
- Case Management and/or homecare experience preferred
- Bilingual in Karen or Spanish preferred
Knowledge, Skills, and Abilities
- Must possess the required level of skills and abilities to read, write, speak, and apply mathematical concepts and sound reasoning to successfully perform the essential duties and responsibilities of this job
- Must be able to perform basic operations on a computer within the Windows operating system and the HRMC EMR
- This position requires problem solving skills, critical thinking skills, and the ability to multi-task
- Comply with safety principles, laws, regulations and standards associated with, but not limited to HIPAA, CMS, and OSHA
- Commitment to the daily application of HRMC's mission, vision, and values to serve patients, their families, and the community
BenefitsHuron Regional Medical Center offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, sick leave and paid time off. To review your benefit eligibility, visit HRMC Benefits .