Full Job Description
General Summary: The Registered Nurse (RN) is responsible for coordinating screening and developing interventions for patients identified as having complex chronic care needs. The RN acts as a connector between patient needs and the resources provided by the care management program. The RN assess patient health concerns and needs, develops and implements nursing care plans, and maintain patient records in accordance with Patient Centered Medical Home model of care.
The mission of Esperanza Health Centers is to deliver health and hope to Chicago’s underserved communities.
Bringing compassion, respect and understanding to all those we serve
Striving for excellence and innovation in every aspect of our work
Building a shared sense of community where every person feels welcome and at home
Principle Duties and Responsibilities:
1. Identifies, tracks and manages care for high-risk patients in collaboration with the entire care team. High-risk patients include individuals or families with co-morbidities such as diabetes, HTN, asthma and/or psychosocial issues.
2. Conducts initial care coordination screening eligibility and performs comprehensive risk assessment and medication reconciliation.
3. Oversees the development and implementation of an integrated patient care plan for each of the highest risk patients.
4. Responsible for achieving Care Management metrics including: transitions of care after admission, timely completion of care plans, decrease in hospital overutilization.
5. Responsible for the delivery of patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation.
6. Responsible for triage of patients who present for urgent care in the health center.
7. Assists with competency activities for Medical Assistants to ensure appropriate level of clinical skills and knowledge.
8. Contributes to the provision of quality nursing care through performance improvement techniques that demonstrate positive outcomes in patient care, with attention to population based measures.
9. Participates in center-wide training events and health related activities.
10. Participates in peer review chart audits.
11. Responsible for meeting the established standards of his/her profession and for practicing within the scope of licensure.
12. Performs all other duties as assigned.
13. Supports the organizational vision and mission.
Generally pleasant work environment. Generally M-F, 8-4:30, and one Saturday a month.
Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.
1. EDUCATION: Bachelors of Science in Nursing (BSN) from a college or university.
2. EXPERIENCE (Preferred):
a. Two or more years working in a clinical setting.
b. Two or more years working with a Latino population.
3. Fluency in Spanish.
4. Ability to multi-task in fast paced environment.
5. Prior experience with electronic health records.
1. Graduate of an accredited School of Nursing.
2. Currently licensed or eligible for licensure in the State of Illinois.
3. Basic Life Support Certification, unless a doctor's release is provided, in which case, yearly proficiency must be demonstrated through oral and written testing.
4. Proficient oral and written communication skills.
1. Prior experience working in an outpatient setting.