RN Care Coordinator - Community Prevention and Treatment Services (req 101095)

GENERAL RESPONSIBILITIES

The Registered Nurse (RN) Care Coordinator serves as a member of the Community Prevention and Treatment Services (CPTS) Team. Working directly with patients who are living with infectious diseases and experiencing social drivers of health (SDOH)—often serving as barriers to care. The Care Coordinator RN will provide gender-affirming care to individuals living with HIV and/or Hepatitis C, substance use disorder (SUD), members of the LGBTQIA+ community, and individuals seeking integrated care. Using principles of the Patient Centered Medical Home (PCMH), the Care Coordinator (RN) will demonstrate professional nursing practice, excellent communication and critical thinking skills, self-management expertise along with outstanding customer service. The Care Coordinator RN serves to assist individuals with care management, prevention, testing and counseling; while assisting patients with chronic disease management and wellness promotion. The Care Coordination (RN) will assist in the coordination and integration of medical and behavioral health working with the patient to achieve optimal health.

SPECIFIC RESPONSIBILITIES

• Utilizes evidence based practice standards, PCMH guidelines, and knowledge of Chronic Illness to provide quality care management for persons living with HIV/AIDS
• Collaborates with providers/clinical teams to identify HIV patient population for care coordination based on quality reports, lab/diagnosis criteria, and provider recommendations
• Carefully coordinates care for patients receiving HIV and gender affirming care, including assistance with referrals, providing medication education and connecting patients to internal/external services
• Participates in State and Federal Ryan White Program HIV trainings, conferences, and meetings
• Participates in HIV related educational events with patients including quarterly Client Advisory Board (CAB)
• Collaborates with members of the HIV team and Quality Improvement Committee—tracking HIV metrics and participates in quality improvement projects related to HIV and gender affirming care
• Facilitates referrals to behavioral health, substance abuse, specialty care and other community-based resources to address social drivers of health (SDOH)
• Supports patients living with HIV with medication education, community linkage and counseling to achieve and maintain viral suppression
• Participates in HIV clinical meetings with patients across the WYH network of care
• Aids patients across the WYH network of care with linkage to counseling across the HIV care continuum including STI testing, Pre-exposure prophylaxis (or PrEP), and Post-exposure prophylaxis (PEP)
• Collaborates with medical case managers to ensure all patients with HIV are connected to care in a timely manner
• Serves as point of contact for patients requiring assistance with clinical HIV needs and triages needs to other team members as indicated
• Demonstrates excellence in both internal and external customer service, along with patient engagement
• Understands and effectively communicates HIPAA compliance, corporate compliance and client confidentiality
• Ensures and remains in compliance with local, state, and federal regulation (FQHC), i.e. DHHS HRSA, CMS guidelines, and NYSDOH (article 28), and all accreditation standards (e.g. Joint Commission and NCQA-PCMH)
• Completes other duties as assigned

MINIMUM QUALIFICATIONS

• Associates degree/graduate of a registered approval program for Registered Professional Nurses with current NYS registration
• Two (2) years’ experience in a health care setting
• Demonstrated excellent customer service, good communication, and interpersonal skills
• Proficiency with computer use

PREFERRED QUALIFICATIONS

• Bachelor’s degree in Nursing and/or two (2) years’ experience working with patients with chronic conditions and care coordination in a medical setting
• Experience working with HIV population a plus
• Flexibility in schedule changes
• Training in laboratory/phlebotomy techniques
• Knowledge of managed care requirements
• Bilingual