Outreach Nurse/RN Care Manager

US Lawns; Charlotte (NC); Vor Ort; USD 68.000 - 90.000; Vollzeit

Benefits dieser Stelle

Medical Insurance

Dental Insurance

Vision Insurance

Disability Insurance (Short/Long Term)

Life Insurance

401K with match

Paid Time Off

Holiday Pay

Employee Assistance Program

Zusammenfassung

Charlotte Community Health Clinic is seeking an Outreach Nurse/RN Care Manager to educate patients, coordinate care, and manage outreach across two sites: Hope Haven and Ophelia-Garmon Brown Medical Clinic.

The role requires nursing licensure in NC, 2+ years in care management, and strong communication; Epic experience is a plus. Travel between sites is required; schedule is Mon-Fri 8-5, exempt.

Qualifikationen

• Associate's degree in nursing required; Bachelor's/Master's preferred.
• Active NC RN license (or multi-state) for North Carolina.
• 2+ years in care management; 4+ years direct patient care; BLS within 90 days.
• Experience with Epic is a plus.

Aufgaben

• Provide patient education, outreach, and clinical support to improve access to care.
• Coordinate care management and follow-up for patients with chronic/complex health needs.
• Identify barriers to care and connect patients with community resources.
• Maintain HIPAA compliance and accurate documentation in EHR.
• Engage in community events and health screenings as needed.

Kenntnisse

Communication skills

Bilingual (Spanish/English)

Independent worker

Team collaboration

Travel between sites

Ausbildung

Associate's degree in nursing

Bachelor's or Master's in nursing (preferred)

Tools

Epic

Jobbeschreibung

Job Description

Title: Outreach Nurse/RN Care Manager

Classification: Full-Time/Exempt

Schedule: Monday-Friday, 8:00am-5:00pm

Locations: This position will work between the following locations:

• Hope Haven: Mondays, Wednesdays, and Thursdays (24 hours/week)
• Ophelia Garmon-Brown Medical Clinic: Tuesdays and Fridays (16 hours/week)

Position Summary

The Outreach Nurse/RN Care Manager will provide patient education, care coordination, care management, and patient outreach to patients who face barriers to care, have chronic health conditions, and have complex medical needs. This position encompasses direct patient care and coordinating care management initiatives. The individual in this role will work between two locations: Hope Haven (direct patient care/outreach) and Charlotte Community Health Clinic’s Ophelia-Garmon Brown Medical Clinic (care management).

CCHC Core Requirements

1. Patient Centered Customer Service – Whether directly or indirectly, we work to support the delivery of an excellent patient experience to everyone served by the organization.
2. Caring and Compassion – We provide empathic comfort to those in distress and share kindness in all interpersonal interactions.
3. Respectful Communication – We communicate openly, honestly and without judgment while honoring each individual’s uniqueness and assuming the best of those with whom we interact.
4. Teamwork – We are members of a diverse interdisciplinary team working together to meet a common goal.
5. Accountability – We accept our individual and team responsibilities, and we meet our commitments. We take responsibility for our performance and actions.
6. Customer Safety – We recognize and correct potential hazards to protect our customers and ourselves.

Key Responsibilities

Patient Outreach:

Provides patient education, outreach, and clinical support to improve access to care and promote positive patient outcomes. This position serves patients experiencing homelessness/instability, those with chronic diseases, patients experiencing substance use challenges, individuals who are in a transitional period in their life/medical journey, those with food insecurity, etc.

• Provides age-specific patient care by assessing, implementing, evaluating, and documenting patient needs, nursing actions taken, and patient responses to care. Updates patient chart.
• Gathers information, reviews past allergic reactions, administers medications and treatments within scope of practice.
• Shares patient information with provider to facilitate care evaluations and follows direction from provider.
• Makes patient referrals as directed by the provider, to resolve identified problems or reach established patient goals.
• Reviews orders for clarity and appropriateness.
• Reaches out to patients who are overdue for or have missed appointments to re-engage.
• Identifies patients who will benefit from community resources and care management.
• Identifies patient learning needs, incorporates into care by providing education and counsel to patients, and documents patient understanding;
• Helps to facilitate that care provided is consistent with policies, procedures and telephone triage protocols, in cooperation with the physician;
• Able to function in emergency situations and facilitates the care provided for all patients;
• Provides high-quality, safe, and thorough patient care.
• Serves as an advocate for the patient.
• Maintains all appropriate licensure.
• Understands and follows HIPAA guidelines and regulations.
• Ensures all test results, in-house and referred, are reported to the provider by checking a manifest or providing oversight of pending labs.
• Performs CLIA waived tests.
• Participates in community events, health fairs, medical screenings, etc. as needed.
• Performs other duties as assigned.
• Care Management:
• Addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes.
• Completes comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs.
• Provides continuous follow up and support for patients experiencing chronic or complex health issues.
• Develops, reviews, and evaluates care plan in partnership with the patient, caregiver/family members, providers, and Care Management team members, as applicable.
• Works with patients to identify various contributing factors that relate to their diagnosis, treatment, and access to care.
• Identifies and addresses barriers that impede health outcomes.
• Implements care management interventions per the patient’s care plan.
• Works in conjunction with the patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities.
• Provides education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management.
• Monitors quality and effectiveness of interventions for the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families.
• Processes referrals to members of the patient engagement team) and/or clinical team in an accurate and timely manner (in accordance with established workflows).
• Serves as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services without duplication.
• Works collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes.
• Maintains appropriate member documentation in the Care Management documentation platform, in accordance with organizational policies and procedures.
• Engages and maintains collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization.
• Abides by department guidelines, company policies, and HIPAA regulations.
• Attends departmental and organizational meetings, local and regional trainings, and other events as required.
• Performs other duties as assigned.

Minimum Qualifications

• Associates’ degree in nursing. A Bachelor’s or Master’s degree in nursing is preferred.
• Active and unencumbered NC RN license or multi-state license that encompasses lawful practice in North Carolina.
• 2+ years of experience in care management.
• 4+ years of experience in direct patient care, preferably primary care.
• Current BLS certification. Must be obtained within 90-days of employment.
• Prior experience with Epic is a plus.

Other Skills, Knowledge, and Abilities

• Excellent communication skills, both written and oral.
• Ability to work independently and collaboratively within an interdisciplinary team.
• Proficient with electronic health records (Epic highly preferred).
• Maintain the highest level of confidentiality and follow all HIPAA regulations.
• Bilingual in Spanish and English highly preferred.
• Experience working in an FQHC environment is highly preferred.
• Ability to pivot and adapt in a fast-paced healthcare environment.
• Proficient with Microsoft Office Suite.
• Accepts and learns from constructive criticism.
• Maintain continuous education to stay current with healthcare best practices and new technology.
• Ability to effectively work with patients, colleagues, community partners, etc. that come from various backgrounds.
• Must have reliable transportation and valid NC driver’s license. Ability to travel between multiple sites as needed.

Physical Demands and Work Environment

The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job. All duties and responsibilities are subject to possible modification to reasonably accommodate individuals with disabilities.

The physical demands associated with this position include but are not limited to: frequent lifting, bending, climbing, stooping, and pulling; frequent repetitive motions; continuous standing and walking; repetitive movement of hands and fingers (typing and/or writing); lifting of greater than 50 pounds.

The noise level in the work environment is low, consistent with that of a typical office.

Charlotte Community Health Clinic, Inc. is an Equal Opportunity Employer. We do not discriminate in any aspect of employment with regard to age, race, sex, national origin, disability, color, marital status, veteran’s status, or religion.

Company Description

Started in 2000 by a group of committed volunteers, Charlotte Community Health Clinic is a Federally Qualified Health Center (FQHC) that offers high-quality medical, dental, and behavioral health services for childrenand adults.

Although we serve all populations, as a FQHC, we have a special purpose of serving the underserved. We work towards a healthy community where all individuals, regardless of ability to pay, have access to affordable, quality, and comprehensive health care. We accept most major health insurance plans, as well as Medicaid and Medicare. For patients without health insurance, we offer a discount program based on income and family size.

Our organization is growing! We are thrilled about the expansion of care that our growth allows us to provide. Our goal is to recruit, develop, and retain a team that not only meets the minimum job qualifications, but shares our passion for serving those who need it most.

For more information about us, use the link below:

https://charlottecommunityhealth.org/en/

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Short Term & Long Term Disability
• Life Insurance
• 401K Retirement Plan w/ discretionary match
• Paid Time Off (PTO)
• Holiday Pay
• Employee Assistance Program (EAP)

EO Employer

Charlotte Community Health Clinic, Inc. is an Equal Opportunity Employer. We do not discriminate in any aspect of employment with regard to age, race, sex, national origin, disability, color, marital status, veteran’s status, or religion.