Join our practice in an RN role that functions beyond traditional triage, emphasizing chronic disease management, quality oversight, clinical staff leadership, and value-based care within an adult primary care practice.
Chronic Disease Case Management
- Manage patient populations with chronic conditions including:
- Diabetes
- Hypertension
- Hyperlipidemia
- Heart failure
- COPD and asthma
- Chronic kidney disease
- Obesity
- Depression and anxiety
- Develop individualized care plans in collaboration with providers.
- Monitor disease-specific quality metrics and clinical outcomes.
- Perform medication adherence assessments and reconciliation.
- Coordinate specialty care and community resources.
- Conduct transitional care and post-hospital follow-up calls.
- Identify high-risk patients requiring intensified care management.
Patient Education
- Provide education regarding:
- Disease management
- Medication administration and adherence
- Lifestyle modifications
- Nutrition and exercise
- Smoking cessation
- Preventive screenings
- Vaccinations
- Self-monitoring techniques
- Reinforce provider treatment plans.
- Utilize motivational interviewing techniques to improve patient engagement.
- Document patient education and understanding.
Quality Improvement & Population Health
- Monitor practice quality measures, including Medicare, commercial payer, and value-based care metrics.
- Identify care gaps and coordinate outreach for preventive services.
- Assist with annual wellness visits and preventive care initiatives.
- Participate in quality improvement projects.
- Support compliance with Patient-Centered Medical Home (PCMH) standards.
- Assist with HEDIS, MIPS, and other value-based reporting initiatives.
- Monitor immunization and preventive screening compliance.
- Participate in clinical audits and performance improvement activities.
Clinical Staff Oversight
- Provide clinical guidance and mentorship to Medical Assistants, LPNs, and other clinical support staff.
- Monitor competency and adherence to clinical protocols.
- Assist with orientation and ongoing training of new employees.
- Ensure appropriate delegation of clinical duties.
- Promote teamwork and effective communication among staff.
- Assist leadership in maintaining regulatory compliance.
Care Coordination
- Coordinate care among primary care providers, specialists, hospitals, home health agencies, and community organizations.
- Participate in multidisciplinary care planning.
- Monitor referrals and follow-up appointments.
- Assist patients with navigating healthcare resources.
Compliance & Documentation
- Maintain accurate, timely documentation in the electronic health record.
- Ensure compliance with HIPAA, OSHA, CLIA, CMS, and state nursing regulations.
- Maintain infection prevention and safety standards.
- Participate in regulatory inspections and accreditation activities.
Qualifications
- Current Registered Nurse (RN) license in the applicable state.
- Minimum of 2 years of clinical nursing experience; primary care or ambulatory care experience preferred.
- Experience with chronic disease management, quality improvement, and population health preferred.
- Proficiency with electronic health records (EHR).
Knowledge, Skills, and Abilities
- Strong assessment and clinical decision-making skills.
- Knowledge of evidence-based primary care guidelines.
- Excellent patient education and communication skills.
- Ability to prioritize multiple responsibilities in a fast-paced environment.
- Leadership and supervisory skills.
- Knowledge of value-based care and quality reporting programs.
- Strong organizational and problem-solving abilities.
- Commitment to patient-centered, team-based care.
Pay: From $27.00 per hour
Benefits:
- Health insurance
- Paid time off
Work Location: In person
