Registered Nurse, Chronic Care Nurse Navigator

The Wright Center for Graduate Medical Education; Jermyn (Lackawanna County); Presencial; USD 39.000 - 55.000; A tiempo parcial

Descripción de la vacante

The Wright Center for Community Health is seeking a part-time Registered Nurse, Chronic Care Nurse Navigator to provide telephonic care coordination for patients with chronic conditions. This role requires clinical expertise, patient advocacy, and education.

You will conduct monthly outreach, identify care gaps, collaborate with care teams, reconcile medications after discharge, and document all activities in the EMR, ensuring CMS guidelines are followed.

Formación

• BS in Nursing is required.
• PN RN license in Pennsylvania or eligibility is required.
• BLS Certification is required.
• Experience with electronic health records (EMR) is preferred (Medent a plus).
• Experience with EOS model is strongly preferred.

Responsabilidades

• Conduct monthly outreach to a panel of CCM patients, assessing health status, treatment adherence, and providing health coaching.
• Use EMR reports and registries to identify preventive care gaps and facilitate necessary care.
• Collaborate with patients, PCPs, and care team to develop and update personalized care plans for chronic conditions.
• Perform post-discharge/ED outreach to reconcile medications and schedule follow-ups to prevent readmissions.
• Act as central point of contact for patients, coordinating appointments, testing, referrals, and pharmacy services.
• Maintain accurate EMR documentation of patient encounters and care plan modifications.
• Ensure CCM time-tracking aligns with CMS guidelines and quality standards.

Conocimientos

Care coordination

Health coaching

Clinical nursing

Communication skills

Team collaboration

Documentation

Educación

BS Degree in Nursing

Herramientas

Medent EMR

EMR systems

EOS People Analyzer Tool

Descripción del empleo

POSITION SUMMARY

Registered Nurse, Chronic Care Nurse Navigator is a position involving the provision of exceptional telephonic care coordination to patients with chronic conditions. This role will be a clinical expert, a patient advocate, and a key educator.

Job Type

Part-time

Description

Registered Nurse, Chronic Care Nurse Navigator is a position involving the provision of exceptional telephonic care coordination to patients with chronic conditions. This role will be a clinical expert, a patient advocate, and a key educator.

REPORTING RELATIONSHIPS

This position reports to the Chief Nursing Officer.

Essential Job Duties And Functions

While living and demonstrating our Core Values, the Registered Nurse, Chronic Care Nurse Navigator will:

• Conduct comprehensive monthly outreach to a dedicated panel of at least 40 Chronic Care Management (CCM) patients, assessing health status, evaluating treatment adherence, and providing health coaching.
• Leverage EMR reports and registries to identify outstanding preventative health gaps (e.g., immunizations, diabetic eye/foot exams, cancer screenings) and facilitate necessary care.
• Collaborate with patients, primary care providers, and the care team to establish, implement, and update personalized care plans for complex chronic conditions (e.g., diabetes, hypertension, COPD, CHF).
• Perform timely post-discharge and post-ED outreach to reconcile medications, review discharge instructions, and schedule follow-up appointments to prevent avoidable readmissions.
• Serve as the central point of contact for patients, coordinating appointments, diagnostic testing, specialist referrals, and pharmacy services.
• Maintain accurate, timely, and complete documentation of all patient encounters, interventions, and care plan modifications within the Electronic Medical Record (EMR).
• Ensure all care coordination and CCM time-tracking activities strictly adhere to Centers for Medicare & Medicaid Services (CMS) guidelines and quality standards.

Requirements

• Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• BS Degree in Nursing
• Registered Nurse in the state of Pennsylvania
• Previous experience in a health center setting a plus
• BLS Certification
• Experience with electronic health record, Medent a plus
• Ability to work as part of a care team
• Excellent communication skills
• Commitment to process improvement and quality

Notice of AI Use in Job Application Review

As part of our commitment in creating a fair, efficient, and consistent hiring process we may use artificial intelligence (AI) to help our recruiting teams organize, summarize, and analyze information provided by candidates, including resumes, application responses, and other materials submitted during the application process.AI may be used to identify patterns, highlight relevant skills, and experience, and assist in comparing a candidate’s qualifications with the requirement of a specific role. These tools are to improve efficiency and consistency while supporting more informed hiring decisions, which will ultimately be made by the hiring team.