Chronic Care Nurse Coordinator

Schedule/Hours: 30-40 hours/week; flexible, subject to Clinical Director's approval

Report to: Clinical Director

Position Summary: Full-time (40 hrs. per week) or Part-time (30 hrs. per week) optional. Provides self-management education and care coordination for patients with, or at high risk for, chronic disease including but not limited to- diabetes, hypertension, COPD, heart failure, depression.

Position Details:

• Serves as a member of the patient-centered care team, providing care coordination in accordance with the patient's individual care plan, consistent with evidence-based guidelines, and in regular consultation with the providers and other members of the care team.
• Participates in daily huddle to review schedule and assign follow-up tasks as necessary
• Active involvement in the development of the patient's care plan and follow-up, including patient self-management
• Communicates with patients in person, email, or other approaches to facilitate care coordination
• Documents all communications with the patient and records patients' progress in the electronic medical record.
• Designs or identifies, and implements patient education programs and materials to assist in self-management
• Works to connect patients to appropriate community resources based on patient need
• Participates in training on evidence-based approaches to patient self-management, population management and effective patient communication
• Participates in quality improvement, including identifying areas for improvement based on performance measurement and patient survey data
• Oversees duties and functions of clerical and medical assistants as assigned by clinical director

Work with a compassionate team

Required Qualifications:

Education: Bachelor of Science in Nursing with relevant experience; will consider associate prepared registered nurse with 5-10 years of experience.

Experience: a minimum of two years' experience caring for patients with chronic disease, especially diabetes and hypertension; experience working as a team member to coordinate care with the patient and the patient's family; experience as a patient educator; familiarity with electronic medical records.

Licensure/Certification: Current Ohio license as Registered Nurse

Desired Qualifications/Abilities:

Experience working in a clinical environment; interest in serving a vulnerable population; understanding of and commitment to evidence-based practices and quality improvement; understanding of and/or experience working in a patient-centered medical home practice highly desirable.

Hours flexible 30 - 40 hrs