Zufall Health Center
PCMH Nursing Coordinator
Zufall Health Center, Dover, New Jersey, us, 07801
PCMH Nursing Coordinator
Dover, NJ, USA
Req #10986
Friday, November 1, 2024
Welcome to Zufall Health!
Position Summary
The PCMH Nursing Coordinator works in collaboration with the patient, family, providers, clinical support team and office staff and within the team structure, to ensure the provision of patient-centered, cost effective, high quality care. Patients under the care of the Coordinator will be supported by the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.
Essential Functions, Duties, and Responsibilities
Identify patients within the team with anticipated high cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease
Link patients with community resources to facilitate referrals and respond to social service needs
Utilize referral protocols and agreements with subspecialists to meet patients’ needs and achieve goals and objectives in their plan of care
Track and support patients when they obtain services outside the center such as the Emergency Department, hospitals and other subspecialists
Follow up with patients within a few days of an emergency room visit or hospital discharge
In collaboration with providers, communicate test results and care plans with patients and families
Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical team
Provide relevant self-management support, including patient education, for patients with chronic illnesses as identified by clinical teams
In collaboration with provider, provide skilled nursing services appropriate to the scope of a community health center including provision of wound care
In collaboration with the behavioral health team and provider, coordinate the clinical preparation and care for Medication Assisted Treatment for patients with a Substance Use Disorder
Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals
In collaboration with administrative staff and enabling services, assist patients with the process of determining eligibility and to obtain and maintain free pharmaceuticals through the Patient Assistance Program
Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns
Address patient and family concerns and initiate corrective action. Bring identified issues to the attention of supervisor
Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
Triage patients who present to the health center and who require evaluation for routine, acute, emergent, or urgent care
Handle phone calls from patients seeking medical information and/or medical attention.
Schedule appointments as the patient’s condition requires answer questions, and provide limited health education
Furnish medical advice per approved triage reference books
Process medication refill requests
Correctly assess stat triage patient’s vital signs and charts them accurately
Assist the office staff to appropriately identify the patient’s acute needs and direct that patient to receive the care required
Assist in transfers to hospital
Assist in the collection of data and preparation of reports and registries for review by the QA/PI Committee
Ensure timely documentation in Electronic Health Records
Participate in Performance Improvement/Continuous Quality Improvement activities
A dhere to policies/safety practices established by the Zufall Health Center
Maintain confidentiality of all patient information
Work effectively with other members of the health care team to optimize interventions.
Serve as subject matter expert in POS labs, duties of Medical Assistant, Clinical Competencies, Standing orders
Assess annual competencies for the Medical Assisting Staff
Oversee orientation of new Medical Assistants, assigning them to preceptors for orientation, tracking orientation progress through the use of the Medical Assistant Orientation checklist, provide feedback to Site Manager as necessary
Work with the CMA’s, providers, DON and clinical pharmacist to maintain pharmacy stock, order medications, evaluate ordering history and make recommendations for changes to medication formulary to meet the needs of the providers and site
In collaboration with DON, work with other sites as necessary to assist with MA training and Competency Assessment
Maintain/rotate the VFC/317 vaccine stock to prevent vaccines from expiring or running out. Order vaccines in a timely manner. Assist with maintaining the registry. Serve as subject matter expert on NJIIS and VFC/317 for both children and adults
Performs other duties as assigned by Director of Nursing and Chief Medical Officer
Knowledge, Skills and Abilities
Possess th orough knowledge of practical nursing theory, standard practices, rules, and regulations related to nursing, knowledge of anatomy and physiology, and knowledge of aseptic technique
Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals
Excellent verbal and written communication skills
Bilingual in Spanish/English
Ability to anticipate primary care provider’s needs
Excellent computer skills, experience with electronic medical records a plus
Ability to interact with patients, staff and outside agencies appropriately
Ability to follow instructions, given either orally or in writing
Ability to work independently or with little supervision
Excellent organizational skills such as problem solving, decision making, priority setting, and work delegation
Ability to complete assignments in a timely manner
Ability to work as a team member
Ability to maintain HIPAA compliance, corporate compliance and client confidentiality
Education, Training and Experience
Licensed Practical Nurse or Registered Nurse training
Current license Registered Nurse in the State of New Jersey
One to two years’ experience in a clinical setting, including direct patient care and triage experience
Prior experience in an ambulatory care or outpatient clinic setting and case management experience preferred
As a condition of employment, we require that all staff are fully vaccinated against flu. Therefore, if hired during flu season (typically between September-May), all new employees need to be fully vaccinated against flu and are required to provide documentation of receiving flu vaccines upon hire.
Zufall Health an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, disability status, medical conditions related to pregnancy or childbirth, protected veteran status, or any other characteristic protected by law. Thank you for taking the time to apply!
Other details
Job Family Clinical
Pay Type Salary
Min Hiring Rate $73,000.00
Max Hiring Rate $80,597.90
Dover, NJ, USA
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Dover, NJ, USA
Req #10986
Friday, November 1, 2024
Welcome to Zufall Health!
Position Summary
The PCMH Nursing Coordinator works in collaboration with the patient, family, providers, clinical support team and office staff and within the team structure, to ensure the provision of patient-centered, cost effective, high quality care. Patients under the care of the Coordinator will be supported by the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.
Essential Functions, Duties, and Responsibilities
Identify patients within the team with anticipated high cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease
Link patients with community resources to facilitate referrals and respond to social service needs
Utilize referral protocols and agreements with subspecialists to meet patients’ needs and achieve goals and objectives in their plan of care
Track and support patients when they obtain services outside the center such as the Emergency Department, hospitals and other subspecialists
Follow up with patients within a few days of an emergency room visit or hospital discharge
In collaboration with providers, communicate test results and care plans with patients and families
Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical team
Provide relevant self-management support, including patient education, for patients with chronic illnesses as identified by clinical teams
In collaboration with provider, provide skilled nursing services appropriate to the scope of a community health center including provision of wound care
In collaboration with the behavioral health team and provider, coordinate the clinical preparation and care for Medication Assisted Treatment for patients with a Substance Use Disorder
Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals
In collaboration with administrative staff and enabling services, assist patients with the process of determining eligibility and to obtain and maintain free pharmaceuticals through the Patient Assistance Program
Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns
Address patient and family concerns and initiate corrective action. Bring identified issues to the attention of supervisor
Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
Triage patients who present to the health center and who require evaluation for routine, acute, emergent, or urgent care
Handle phone calls from patients seeking medical information and/or medical attention.
Schedule appointments as the patient’s condition requires answer questions, and provide limited health education
Furnish medical advice per approved triage reference books
Process medication refill requests
Correctly assess stat triage patient’s vital signs and charts them accurately
Assist the office staff to appropriately identify the patient’s acute needs and direct that patient to receive the care required
Assist in transfers to hospital
Assist in the collection of data and preparation of reports and registries for review by the QA/PI Committee
Ensure timely documentation in Electronic Health Records
Participate in Performance Improvement/Continuous Quality Improvement activities
A dhere to policies/safety practices established by the Zufall Health Center
Maintain confidentiality of all patient information
Work effectively with other members of the health care team to optimize interventions.
Serve as subject matter expert in POS labs, duties of Medical Assistant, Clinical Competencies, Standing orders
Assess annual competencies for the Medical Assisting Staff
Oversee orientation of new Medical Assistants, assigning them to preceptors for orientation, tracking orientation progress through the use of the Medical Assistant Orientation checklist, provide feedback to Site Manager as necessary
Work with the CMA’s, providers, DON and clinical pharmacist to maintain pharmacy stock, order medications, evaluate ordering history and make recommendations for changes to medication formulary to meet the needs of the providers and site
In collaboration with DON, work with other sites as necessary to assist with MA training and Competency Assessment
Maintain/rotate the VFC/317 vaccine stock to prevent vaccines from expiring or running out. Order vaccines in a timely manner. Assist with maintaining the registry. Serve as subject matter expert on NJIIS and VFC/317 for both children and adults
Performs other duties as assigned by Director of Nursing and Chief Medical Officer
Knowledge, Skills and Abilities
Possess th orough knowledge of practical nursing theory, standard practices, rules, and regulations related to nursing, knowledge of anatomy and physiology, and knowledge of aseptic technique
Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals
Excellent verbal and written communication skills
Bilingual in Spanish/English
Ability to anticipate primary care provider’s needs
Excellent computer skills, experience with electronic medical records a plus
Ability to interact with patients, staff and outside agencies appropriately
Ability to follow instructions, given either orally or in writing
Ability to work independently or with little supervision
Excellent organizational skills such as problem solving, decision making, priority setting, and work delegation
Ability to complete assignments in a timely manner
Ability to work as a team member
Ability to maintain HIPAA compliance, corporate compliance and client confidentiality
Education, Training and Experience
Licensed Practical Nurse or Registered Nurse training
Current license Registered Nurse in the State of New Jersey
One to two years’ experience in a clinical setting, including direct patient care and triage experience
Prior experience in an ambulatory care or outpatient clinic setting and case management experience preferred
As a condition of employment, we require that all staff are fully vaccinated against flu. Therefore, if hired during flu season (typically between September-May), all new employees need to be fully vaccinated against flu and are required to provide documentation of receiving flu vaccines upon hire.
Zufall Health an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, disability status, medical conditions related to pregnancy or childbirth, protected veteran status, or any other characteristic protected by law. Thank you for taking the time to apply!
Other details
Job Family Clinical
Pay Type Salary
Min Hiring Rate $73,000.00
Max Hiring Rate $80,597.90
Dover, NJ, USA
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