Full Time RN-Family Practice-Eaton Rapids

DescriptionExcellent communication skills.Work collaboratively with the clinical team to complete AWV's by following protocols and standing orders .Stratify patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointment and CCM encounters. Maximize use of qualified clinical staff to provider appropriate non-face-to-face patient contact.Provide clinical health coaching interventions to motivate patients and families towards successful self-management of chronic disease. Effectively partner with provider practice team members to mobilize needed community resources.In collaboration with the PCP, develop a care plan based on mutual goals with the patient, family, provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.Receives telephone calls that require nursing assessment, talks directly to patients, and instructs them on their next course of action. Address EHR/portal messages and prescription refill requests.Participates in quality improvement initiatives.Educate patients and families on various health conditions, disease prevention, medication regimens, and lifestyle modification empowering our patients to actively participate in their own care.Works with an interdisciplinary team including Physicians, APP's, Caseworker, LPN/MA's , and other health professionals to coordinate care, share information, and ensure seamless continuity of care.Documents patient encounters according to nursing standards and policies.Reviews and places orders in collaboration with the PCP (prescription refills, supplies, labs, diagnostic imaging).Provides routine nursing support (Nurse Visits)as directed by Providers and approved as standard practices (e.g., office surgical procedures, nurse visits, wound dressing changes, suture removal, vaccines, injections, etc.).Assist with conducting yearly Medical Assistant competencies and providing clinical education, as needed.Assist with basic MA job responsibilities, as needed.RequirementsGraduate of an accredited school of nursing, and currently licensed to practice in the state of Michigan. BLS required upon hire and maintained throughout employment. ACLS and PALS required within 90 days of employment and maintained throughout employment. 3-4 years' experience in quality or chronic care management, or equivalent experience. Previous experience in caring for chronic care disease patients required. Previous Population Health, Care Coordination, Case Management, Home Health, or Behavior Health experience preferred. 3-5 years' experience in ambulatory care setting preferred. Previous experience with utilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.