RN/Chronic Care Coordinator - Bay Care Medical Center

Clinic RN/Chronic Care Coordinator

The Clinic RN / Chronic Care Coordinator provides direct and indirect patient care that meets the psychosocial, physical and general needs of the patients. The Chronic Care Coordinator is responsible for supporting and coordinating the physical health care of patients on an assigned patient caseload with the patient's medical provider and, when appropriate, other specialists. The Clinic RN/ Chronic Care Coordinator maintains regulatory agency requirements, nursing, and hospital policies, procedures, and standards.

Clinic RN Essential Functions:

• Prepares patient and equipment required for examination and treatment by the provider.
• Assists the provider with patient examination and testing.
• Prepares treatment room, calls patients from waiting area, and obtains the patients chief complaint.
• Records height, weight, blood pressure, pulse, temperature, and instructs patient in obtaining urine samples.
• Obtains reports of laboratory and radiology results.
• Administers and records injections.
• Coordinates prescription refills and mail order prescriptions for patient.
• Performs random and scheduled drug screens per federal regulations.

Chronic Care Coordinator Essential Functions:

• Assist the Clinic Manager with the development of a Chronic Care Management Program for Clinic patients.
• Engage patients, inform them of their needs, and empower them and their families to achieve understanding of their chronic disease management process.
• Screen patients for medication adherence, social determinants of health, and physical needs.
• Facilitate patient engagement and follow-up care.
• Provide patient education about chronic disease management, as well as available financial, social and community resources.
• Monitor and take responsibility for a patient population as well as track on up to date preventative measures.
• Systematically track treatment response and monitor patients (by telephone) for changes in medication adherence and physical health.
• Provide resources when appropriate.
• Collaborate with provider to assist in initiating an individual care plan with goals for patient.
• Track patient follow up and clinical outcomes using a care plan.
• Document telephone encounters in the care plan and use the system to identify and re-engage patients.
• Assist clinic manager with quality measures/PCMH.