Registered Nurse (RN) - OB

Primary Responsibilities

• Participates as an integral part of a multi-disciplinary team for the comprehensive health care of clients and their families.
• Provides triage assessment, consultation, and referral for FCHC clients contacting FCHC through the telephone, patient portal and directly in clinic.
• Schedules same day appointments in conjunction with provider.
• Provides appropriate education and home care advice.
• Obtains information for clients requesting test results and medication refills.
• Documents assessment, patient education, nursing interventions, and encounter notes in the EMR.
• Sends refill requests to appropriate provider and completes prior authorization if needed by insurance.
• Performs routine direct patient care such as administering injections, dressing changes, vital sign assessment and other requested and necessary RN duties.
• Develops individualized care plan setting mutual health goals with patient/family for patients with acute conditions, complex conditions and co-occurring chronic illnesses.
• Provides education about disease processes and management (e.g. diabetes, asthma, and COPD).
• Emphasizes disease prevention and health promotion and addresses the specific needs of the client.
• Consults with members of multidisciplinary care team (Community Health, Nutrition, Behavioral Health, Pharmacy, etc.) about identified health conditions and the tailored interventions necessary to address barriers and challenges to achieving individual health care goals.
• Carefully coordinates care using a care management approach, including risk assessment, coordination and referral, follow-up and tracking, crisis intervention, documentation and modification of care plan as needed, to maintain continuity of patient care.
• Provides medication, education and support to help patients better manage all of their health conditions.
• Performs post-hospital discharge transitions of care encounters and oversees the scheduling of patient for follow-up as appropriate and per clinical protocols (e.g. new onset of illness or diagnosis).
• Documents transition of care encounter, including medication reconciliation, in the EMR.
• Communicates and helps facilitate various direct and indirect patient care activities, which may include Coordination With And Related To Pharmacy Referrals DME, Home Health, PT/OT Insurance Health Care Organizations SchoolsCommunity OrganizationsOther Partners.
• Participates in huddles and pre-visit planning with provider and care team members.
• With the multidisciplinary team, obtains, coordinates, develops, and maintains adequate and appropriate educational materials and teaching tools.
• Works with providers to support team efforts around care coordination and the model for improving metrics established by Health Resources & Services Administration (HRSA), Primary Care Health Home (PCHH), Accountable Care Organization (ACO), and others as identified in partnership or regulatory compliance.
• May attend learning sessions and collaborative calls with FCHC partners, such as Missouri Primary Care Association, Department of Health and Senior Services, and others, to facilitate best practices within the RN role.
• May interface with DRVS and Cyber Access to monitor effectiveness of individual care plans for patients with Medicaid coverage.
• Provides essential support and assistance to other RN team members to ensure team success and consistent and quality patient care.
• As part of the health care team, responds to medical emergencies in the office.
• Acts as a resource for Medical Assistants and other personnel as needed.
• Participates in facilitating a learning environment for students.
• Collaborates with self-directed management teams to continuously improve the delivery of health services.

Periodic Duties

• Participates in Health Center staff problem solving groups.
• Attends and participates in department meetings, etc.
• Identifies and presents appropriate educational materials for different audiences.
• Presents information to various audiences.
• Participates in data analysis and quality assurance.
• Performs other duties as assigned.

Working Relationships

• Inside Center: All inclusive.
• Outside Center: Patients/Clients, students, vendors, community health agencies, hospitals, physician’s offices, Dept of Health & Social Services, etc.