Team Nurse

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 85,000 - 95,000; Full time

Benefits offered by this job

Sign-on bonus up to $2,500

Job summary

AbsoluteCARE Medical Center & Pharmacy is seeking a Registered Nurse to support primary care activities for the PCP panel, including patient education, orders, referrals, and medication management. The Team Nurse works with members to achieve care plan goals through education, care coordination, and relationship-building.

The role includes panel management, disease pathways, standing orders for preventive care, and closing care gaps.

Qualifications

• Active, unrestricted RN license in the practicing state (Compact license preferred)
• 3+ years of clinical experience with adults and geriatrics with chronic conditions
• Active CPR certification
• Experience with community-based care settings is a plus
• Strong communication, problem solving, and organizational skills

Responsibilities

• Support primary care providers and PCP panel activities
• Manage diagnostic orders, refills, chart review, and patient messages
• Lead panel management to close care gaps and follow disease care pathways
• Coordinate follow-ups and ensure timely appointments with members
• Provide in-person and telephonic care coordination and education
• Assist with medication reconciliation and disease management coaching
• Triages with the care team and supports daily huddles
• Facilitate referrals within the integrated care team
• Provide coverage and point-of-care testing as needed
• Balance member care with provider panel tasks using strong time management

Skills

Interpersonal communication

Independent self-starter

Organizational skills

Population health

Care coordination

Tools

Microsoft Office

Job description

$85,000 - $95,000

One time sign on bonus up to $2,500

Job Description:

Job Summary

This role works with a dedicated Primary Care Provider and supports primary care activities for the PCP panel, including patient education, orders, referrals, and medication management, and addressing gaps in care. The Team Nurse works directly with members to achieve their care plan goals through patient education, care coordination, and building relationship.

Duties and Responsibilities

• Act as the practice-based nurse, supporting on-site providers in facilitating high quality primary care that promotes appropriate healthcare utilization.
• Facilitate Patient Centered Medical Home (PCMH) functions through management of diagnostic order tracking, medication refills, review of the medical record, and fielding messages from members and the integrated care team.
• Lead panel management for members attributed to the assigned primary care provider through activities including, but not limited to, following disease care pathways, entering standing orders for preventive care, and leveraging available reports to close care gaps.
• Monitor access to the primary care provider. Ensure members have scheduled follow-up.
• Coordinate services to complete primary care provider action plan tasks.
• Meet with members in the medical center as an extension of the primary care provider to address member needs, including medication reconciliation and teaching and coaching for effective disease management.
• Engage members telephonically between primary care visits to support PCMH activities, panel management, and action plan completion.
• Prepare for and participate in daily huddle with the integrated care team.
• Act as a bridge between the primary care provider and the greater integrated care team. Coordinate internal referrals between team members.
• Coordinate with the Immediate Care Area to provide in person and telephonic triage. Perform nursing interventions including wound care, IV (intravenous) therapy, and phlebotomy as needed.
• Provide coverage support for fellow care team members as needed, including point of care testing, medication administration, and office flow.
• Leverage strong time management skills to prioritize and balance member care responsibilities with provider panel management and role-specific tasks.

Minimum Qualifications

• Active, unrestricted license as a Registered Nurse in the state of practice required. Compact RN license preferred, or willingness to obtain.
• 3+ yearsof experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions.
• Active CPR certification.
• Experience working for a community-based organization preferred.
• Proficiency in clinical nursing skills such as wound assessment and care, venipuncture and phlebotomy, and assessment and management of common chronic conditions such as diabetes, hypertension, CHF, and COPD.
• Excellent interpersonal communication,problem solving, and organizational skills.
• Independent self-starter and critical thinker interested in population health, healthcare utilization management, and the ongoing development of our care model.
• Proficiency with Microsoft Office applications.

Working conditions

This job operates in a professional office environment. This role routinely uses general office equipment. Often wear a special uniform, such as a lab coat or surgical scrubs, protective or safety attire, such as gloves and masks. Exposed to the diseases and infections of patients daily. May share workspace with other technicians and staff.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.