Care Team Nurse

Job Duties and Responsibilities

• Work as part of the clinical nursing team to provide a full range of nursing services, including patient assessment, phone advice, case management, care team coordination, provide patient education.
• Review provider/clinician laboratory results on a daily basis, identifying and communicating common items to patients or provider per organizational protocol.
• Review provider/clinician diagnostic imaging reports received from outside agencies and communicate to patients or provider per organizational protocol.
• Refill medications for care team patient panels per established Nursing Protocols.
• Monitor care team patient panels referral status, ensuring documentation is complete, patient compliance or barriers are addressed, and referral completion is documented.
• Work to resolve telephone encounters within 72 business hours of receipt.
• Monitor support team and nurse schedule for appropriate appointment types and cycle times.
• Notify patients of test results and follow up plan per protocol or as directed by provider/clinician.
• Monitor provider's schedules in the care team for available daily access for each care team provider/clinician and that each appointment is appropriate for each individual provider's scope of services.
• Monitor population management activities by support staff, ensuring documentation is complete and interventions are identified in the patient's health record.
• Ensure effective management of the vaccine/immunization programs.
• Develop care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize unnecessary hospital inpatient and ER utilization.
• Utilize behavioral strategies, such as motivational interviewing, to assist patients in adopting healthy behaviors, improving self-care, managing chronic disease, and utilizing in-house resource.
• Assist patients in problem-solving issues related to the health care system, financial and psychosocial barriers.
• Provide ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of follow-up care.
• Communicate/affirm patient needs, plan of care, and changes in status with the patient's PCP, team, and the patient/family.
• Manage care coordination systems for referrals, ordered test completion, and receipt of report from outside providers.
• Supervises and supports integrative behavioral health services.
• Participate in care team meetings to evaluate outcomes of care with the care team.
• Provide leadership to care team support staff.
• Model professionalism and excellent customer service standards.
• Monitoring of Crash cart/AED.
• Other duties as assigned.

Education/Licensing/Training

• High School Diploma or Equivalent.
• Valid RN or LVN California License in good standing with the California Board of Nursing.
• CPR Certification.

Knowledge, Skills and Experience

• Ability to read, write, and communicate in the English language.
• Broad knowledge of principles and practices, care coordination or case management.
• Must possess excellent time management, organizational, and work planning skills.
• Knowledge of personnel management principles.
• Knowledge of health care regulations and guidelines.
• Demonstrated experience in a healthcare, mental health, or social work related field, or any satisfactory combination of experience and training which demonstrates the knowledge, skills and abilities to perform the above duties.
• Medical, Dental and Vision Insurance
• 401(k) with matching
• Generous Paid Time Off, Personal Day, and Holiday packages
• Flexible Spending Account Plan
• Employee Assistance Program
• Life/ADD insurance policy
• Long Term Disability Insurance

Compensation : $80,000.00 to $133,120.00 per year, depending on experience and credentials