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
• 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 resources
• Aid patients in problem-solving issues related to the health care system, financial and psychosocial barriers
• 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
• Supervise and support integrative behavioral health services
• Participate in care team meetings to evaluate outcomes of care with the care team
• Model professionalism and excellent customer service standards
• Monitoring of Crash cart/AED

Requirements

• High School Diploma or Equivalent
• Valid RN or LVN California License in good standing with the California Board of Nursing
• CPR Certification
• Ability to read, write, and communicate in the English language
• Broad knowledge of principles and practices, care coordination or case management
• 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

Benefits

• 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