SUMMARY:

Under supervision of Ambulatory Clinical Manager and Practice Providers, and working within primary and specialty care practice settings, provides comprehensive screenings, assessment, care coordination services, disease education and self-management support to patients with chronic health conditions. Participates as member of multidisciplinary healthcare team to develop Patient-Centered Medical Home environment for patient-centered care. Performs a variety of professional nursing, technical, and administrative duties in assigned medical office setting. Coordinates, assigns, and leads the activities of office staff. Works collaboratively with providers and others to achieve desired cost and quality outcomes.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

RESPONSIBILITIES:

• As member of physician office practice, provides consultation and works collaboratively with providers on patient cases. Reviews or completes initial patient assessment, including comprehensive medical, psychosocial and functional assessment of patient, which may require performing same in patient home setting as necessary. Ensures screening tests are current.
• Provides detailed education about patient’s specific chronic illness, including pathology, signs and symptoms, complications and medications used in treatment.
• Utilizes multidisciplinary team approach to address opportunities to plan and coordinate care.
• Coordinates interactions with ancillary personnel.
• Establishes care management plans, interventions, treatment goals (including self-management goals) and contact schedules:
• Promotes compliance with chronic care plan
• Coordinates care and communicates with multiple providers, both within and external to the practice
• Reviews test results and tracks outcomes; refer test results exceeding acceptable ranges to practitioners
• Reviews patient compliance issues
• Evaluates effectiveness of plan in meeting established care goals
• Revises plan as needed to reflect changing needs, issues and goals
• Arranges group visits
• Performs a variety of professional nursing and technical duties and supervises medical assistants performing similar functions as applicable:
• Performs/records telephone and in-office triage according to guidelines
• Prepares patients for examination. Obtains and records temperature, blood pressure, height/weight, head circumference (newborn)
• Performs diagnostic testing including EKG, Urine dipstick and centrifuge prep for micro slide exam, Vision Screening, Strep, Tuberculin, Tympanometry and Audiometry
• Assists practitioners with examinations, procedures and minor surgeries: applies principles of sterile technique, prepares exam areas, equipment, and supplies, and performs clean-up of patient area per OSHA standards.
• Provides patient education: assesses readiness to learn and barriers to learning, identifies appropriate resources and techniques, prioritizes learning needs, adjusts level of presentation to audience, provides environment conductive to learning, establishes method for evaluation of learning, and evaluates patient’s/families’ response to teaching
• Administers medications considering age specific needs: allergy injections with monitoring, Intramuscular, Subcutaneous, Intradermal, and Oral
• Maintains medical records in compliance with audit standards: obtains patient identification data, reason for visit, pertinent medical history, and written consent for treatment. Dates and signs entries, records known diagnosis, drug allergies, and medications
• Conveys prescription renewal information to pharmacies per practitioner’s direction
• Manages health information such as testing reports, correspondence and other documents: appropriately uses electronic medical record, relays pertinent information to providers for action, and shares files and messages with providers and support staff
• Schedules patient appointments: office visits per provider’s guidelines, outpatient diagnostic services, consultations with other providers, and obtains insurance authorizations as indicated
• Performs medical office leadership functions:
• Organizes, coordinates and leads work of office staff to ensure organizational objectives are accomplished according to established work standards
• Responds to day-to-day needs of patients, providers, and support staff
• Collaborates with Ambulatory Clinical Manager and other Nursing Care Managers to develop master staffing schedules. Jointly coordinates daily staffing and assignment adjustments as needed, adjusting scheduled hours to accommodate patient volume
• Coordinates work flow in offices
• Monitors and accurately reports time worked by staff
• Participates in interviewing/selection of new staff
• Instructs staff in proper work methods, techniques, use and care of equipment, safe working practices, policies and procedures. Coordinates orientation program for new staff
• Assists with development and coordination of staff competency assessments. Conducts and documents introductory and annual competency assessments of staff
• Provides basic reinforcement or coaching to staff as needed. Reports areas of concern to Ambulatory Clinical Manager
• Provides Ambulatory Clinical Manager with routine performance feedback on staff. Provides input for and participates in staff performance evaluations.
• Recommends staff learning needs
• Serves as role model and resource to staff. Participates in employee engagement efforts.
• Maintains adequate inventory of office and clinical supplies.
• Supports administrative functions relative to compliance and organizational standards: preparations for Licensure, Regulatory, and Accreditation, Preparations for Risk Management Safety, Security, and Emergency Preparedness, Compliance with Incident and Medical Event Reporting, Compliance with policies and procedures, and Coordinates CLIA controls maintenance for laboratories
• Maximizes usage of electronic medical record/chronic disease registry reporting to effectively prioritize patient follow up activities.
• Initiates and maintains effective relationships within community as required by patient population. Demonstrates flexibility and creativity in recommending resources to meet patient/family needs, such as identifying and utilizing appropriate cultural and community resources to support needs of diverse patient population.
• Functions as Patient-Centered Medical Home liaison to hospitals, long-term care institutions, specialists and home health representatives to coordinate administrative and clinical issues related to patient care.
• Ensures open communication regarding patient status with physicians and office staff.
• Participates in quality improvement and evaluation processes related to Care Management.
• Reviews pertinent literature about case types managed and best practices in patient-centered medical home to share with team members.

MINIMUM QUALIFICATIONS:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

BASIC KNOWLEDGE:

Current licensure to practice as Registered Nurse in the state of Rhode Island.
Current Basic Life Support Certification.
Professional certification if indicated by the practice specialty.
Demonstrated knowledge and skills necessary to provide care to patients with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
Demonstrated leadership skills.

EXPERIENCE:
At least three years professional nursing experience in community health setting, public health, chronic disease management or community nursing preferred.
Experience should demonstrate thorough knowledge of chronic disease management, with demonstrated effectiveness in coordinating patient care with primary care providers.
Case management experience with patient care coordination and disease management/education preferred.
Experience with specific patient population served by particular practice is required.

SUPERVISORY RESPONSIBILITY:
None.

Pay Range:

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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Driving Required: