RN/Care Coordinator
Full Time
$30-38/hour
https://neighborhoodhealthsource.org/
ESSENTIAL FUNCTIONS & RESPONSIBILITIES:
General Nursing
• Serves as the contact point, advocate, and informational resource for patients, care team,
family/caregiver(s), payers, and community resources
• Handles incoming triage calls:
o Provides appropriate patient education regarding medical condition
o Provides medication instructions
o Supports providers by following up with patients regarding their lab/imaging results as guided
by the provider
o Documents telephone discussions in the patient’s electronic medical record (EMR)
• Handles incoming Nursing Home Orders
• Handles incoming pharmacy questions, clarifications and prior authorizations
• Calls patients with medication changes, directions and education, as ordered by providers
• Provides nursing support, when needed, to the Nurse Midwives and NHS providers
• Utilizes the Patient Portal to communicate with patients
• Sees patients on daily nurse schedule:
o Responds to the needs of walk-in patients
o Assists providers as needed
o Provides education on medical condition, e.g., asthma, diabetes, family planning
o Reads and documents PPD results
• Provides refill requests that come through the EMR, phone or fax
• Reconciles medications
• Maintains a logbook of all dispensed medication at the direction of the medical provider
• Maintains an emergency box of medications
• Oversees the application/enrollment and tracking process for patients in indigent medication
programs
• Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency
• Provides community-based nursing care as established by the organization, as requested
Care Coordination/Case Management Support
• Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:
o Assists with the identification of “high risk” patients (those with chronic illness and/or special
health care needs)
o Contacts patients to enroll them into HCH and documents patient’s acceptance or declination,
to populate the registry
o Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care
and educates patients on when to utilize the ER
o Reviews FUHN/ID Stratification patient’s EMR to see what patients may need; refers to
specialty providers and to helps with medication reconciliation
• Works with patients to plan and monitor care:
o Assesses patient’s unmet health and social needs
o Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan,
health management plan, medical summary, and ongoing action plan, as appropriate)
o Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a
timely manner, and facilitates changes as needed
o Creates ongoing processes for patient and family/caregiver(s) to determine and request the
level of care coordination support they desire
• Facilitates patient access to appropriate medical and specialty providers
• Educates patient and family/caregiver(s) about relevant community resources
• Cultivates and supports primary care and specialty provider co-management with timely
communication, inquiry, follow-up, and integration of information into the care plan regarding
transitions in care and referrals
• Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider
• In collaboration with the primary care provider, assigns the appropriate tiering level based on
required criteria for HCH patients
• Advocates for the participant in understanding needs surrounding transportation, shelter, child
care and safety. Refers participant to behavioral health services if warranted
• Keeps EMR care plans updated for easy access by HCH Team
• Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox
messaging and/or team huddles to update and advance care coordination within the Team
• Utilizes all available tools to deliver education, instruction, care coordination and training,
including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies &
procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease
management brochures; disease management participant tracking records (Diabetes glucose
records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific
educational handouts; services offered by NHS
CORE REQUIREMENTS:
• Works collaboratively and respectfully with staff and others—individually and as part of a team—
to achieve optimal efficiency, outcomes and morale
• Interacts in a culturally competent manner with individuals and groups from diverse backgrounds,
including but not limited to: socio-economics, race and ethnicity, nationality and religion, both inclinic and in the community
• Maintains excellent and punctual attendance
• Attends and actively participates in staff and departmental meetings
• Attends agency functions and meetings as relevant or required
• Works at any or all NHS clinics, as needed
• Uses computer daily including e-mail, word documents, spreadsheets, patient management
system, electronic health record, and patient portal, as needed to carry out essential job functions
• Maintains any required licensure/certification
• Demonstrates commitment to agency mission and goals
• Abides by corporate compliance program, HIPAA regulations and other agency policies and
procedures
• Participates daily in pre-visit planning and huddles (RN, Provider, Medical Assistant, Front Desk)
• Plans, organizes, and multitasks
• Speaks, understands, reads and writes English sufficiently to carry out all essential duties
• Performs other duties as assigned
QUALIFICATIONS
• Graduation from an accredited nursing program
• Current Minnesota RN license
• Minimum one year experience in a primary care setting preferred
• Patient education experience
• Family planning experience highly desired
• Motivated to improve the health of the community
• Excellent interpersonal communication