NYC Health Hospitals
Staff Nurse - Amb Care Svcs
NYC Health Hospitals, New York, New York, us, 10261
Woodhull Medical and Mental Health Center is attuned to the healthcare issues that matter to the people of North Brooklyn. Woodhull focuses on preventing disease and promoting healthy lifestyles by reaching out to the community at various locations.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Work Shifts
0800 - 1630
Job Description
PURPOSE OF POSITIONAmbulatory Care Services; Direct patient care, Assessment, Medication administration, PCMH duties
AREAS OF RESPONSIBILITIESAmbulatory Care Services
SUMMARY OF DUTIES AND RESPONSIBILITIESCare Planning and Self-Management Support1. Works with patient, PCP and other care providers to identify and prioritize patient's health care goals and develop a comprehensive care plan to achieve them.2. Assesses patient knowledge of disease, self-management skills, and readiness to change and administers standardized health risk screening and assessments tools.3. Identifies and monitors measurable outcomes and clinical parameters appropriate for diagnosis, staging of medical conditions, progress towards care plan goals, and early identification of need to referral for urgent/emergent complications.4. Determines and conducts appropriate level of services and follow-up, including using care pathways or protocols to deliver time-limited, goal oriented clinical interventions.5. Provides health education, counseling, coaching and other therapeutic modalities (as appropriate) that may include group classes, one2one encounters and/or telephonic contact to help patient achieve self-management goals.6. Documents all interventions, follow-up and patient care plan progress.
Care Coordination1. Determines and arranges for appropriate treatment options and healthcare services, including necessary referrals to specialists, homecare, and community resources, to achieve optional patient outcomes.2. Coordinates and communicates with PCP and patient's care team on all care plan activities including care plan goals; referrals; transition care planning; and follow-up tracking.3. Consults and collaborates in case review meetings with other care team members and care providers, including behavioral health, disease care management, home-care, social work and community based organizations, to help patient achieve optimal health outcomes.
Population Health Management1. Participates in caseload and team meetings. Reviews new information and complex cases with PCP and multidisciplinary team and incorporates additional recommendations into care plan.2. Conducts pre and post-visit planning and communication with team.3. Collects and reviews data (including chart, reports and registries) to monitor, track and optimize patient panel health outcomes.4. Consults with physician, nursing staff and ancillary department staff to eliminate barriers to efficient delivery of care in the appropriate setting. Identifies system barriers/delays and develops and implements strategies for resolution.5. Collects and analyzes data to proactively identify opportunities to improve process and promote leading practice.
Minimum Qualifications1. A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and2. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).Special Note:For assignments in Post-Acute Care ONLY, individuals meeting the following criteria may also be considered for appointment: Graduation from a nursing education program registered by the New York State Education Department (NYSED) as licensure qualifying for Registered Professional Nurse (RN) and has applied for licensure as an RN. These unlicensed individuals may be employed to practice under the immediate and personal supervision of a NYS licensed, currently registered, RN for up to 90 days immediately following graduation pending receipt of a limited permit, which selected candidates must apply for and receive within the same 90-day period. Once a limited permit is received, individuals can practice nursing, under the immediate and personal supervision of a NYS licensed, currently registered, RN at a NYC Health + Hospitals health care setting for up to one (1) year from the date of issuance of the limited permit. In addition, must hold or obtain through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Work Shifts
0800 - 1630
Job Description
PURPOSE OF POSITIONAmbulatory Care Services; Direct patient care, Assessment, Medication administration, PCMH duties
AREAS OF RESPONSIBILITIESAmbulatory Care Services
SUMMARY OF DUTIES AND RESPONSIBILITIESCare Planning and Self-Management Support1. Works with patient, PCP and other care providers to identify and prioritize patient's health care goals and develop a comprehensive care plan to achieve them.2. Assesses patient knowledge of disease, self-management skills, and readiness to change and administers standardized health risk screening and assessments tools.3. Identifies and monitors measurable outcomes and clinical parameters appropriate for diagnosis, staging of medical conditions, progress towards care plan goals, and early identification of need to referral for urgent/emergent complications.4. Determines and conducts appropriate level of services and follow-up, including using care pathways or protocols to deliver time-limited, goal oriented clinical interventions.5. Provides health education, counseling, coaching and other therapeutic modalities (as appropriate) that may include group classes, one2one encounters and/or telephonic contact to help patient achieve self-management goals.6. Documents all interventions, follow-up and patient care plan progress.
Care Coordination1. Determines and arranges for appropriate treatment options and healthcare services, including necessary referrals to specialists, homecare, and community resources, to achieve optional patient outcomes.2. Coordinates and communicates with PCP and patient's care team on all care plan activities including care plan goals; referrals; transition care planning; and follow-up tracking.3. Consults and collaborates in case review meetings with other care team members and care providers, including behavioral health, disease care management, home-care, social work and community based organizations, to help patient achieve optimal health outcomes.
Population Health Management1. Participates in caseload and team meetings. Reviews new information and complex cases with PCP and multidisciplinary team and incorporates additional recommendations into care plan.2. Conducts pre and post-visit planning and communication with team.3. Collects and reviews data (including chart, reports and registries) to monitor, track and optimize patient panel health outcomes.4. Consults with physician, nursing staff and ancillary department staff to eliminate barriers to efficient delivery of care in the appropriate setting. Identifies system barriers/delays and develops and implements strategies for resolution.5. Collects and analyzes data to proactively identify opportunities to improve process and promote leading practice.
Minimum Qualifications1. A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and2. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).Special Note:For assignments in Post-Acute Care ONLY, individuals meeting the following criteria may also be considered for appointment: Graduation from a nursing education program registered by the New York State Education Department (NYSED) as licensure qualifying for Registered Professional Nurse (RN) and has applied for licensure as an RN. These unlicensed individuals may be employed to practice under the immediate and personal supervision of a NYS licensed, currently registered, RN for up to 90 days immediately following graduation pending receipt of a limited permit, which selected candidates must apply for and receive within the same 90-day period. Once a limited permit is received, individuals can practice nursing, under the immediate and personal supervision of a NYS licensed, currently registered, RN at a NYC Health + Hospitals health care setting for up to one (1) year from the date of issuance of the limited permit. In addition, must hold or obtain through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs