The RN Clinical Care Coordinator functions as a registered nurse responsible for developing, implementing, and evaluating care plans for patients requiring intensive care management, with a focus on chronic conditions such as diabetes and hypertension. Working collaboratively with a multidisciplinary care team—including providers, nurses, dietitians, pharmacists, behavioral health clinicians, and community health workers—the RN Clinical Care Coordinator ensures that high-risk patients receive comprehensive and coordinated care. In addition to direct patient care in the clinic, the RN Care Coordinator will also support quality improvement initiatives and projects, administer vaccines and injectable medications, and perform certain diagnostic procedures (e.g., spirometry, diabetic retinal imaging, etc.).

Full time Position: Yes

Reports to Clinical Pharmacy and Allied Health Manager

Supervises N o

Dress Requirement Business Casual in accordance to Heart of Ohio Family Health dress code.

Work Schedule

Monday through Friday during standard business hours

Times are subject to change due to business necessity

Exempt þ Non-Exempt

Job Duties, these are considered essential to the successful performance of this position:

• Complete nursing assessments and create care plans for patients with complex chronic disease with an emphasis on diabetes.
• Enroll patients in Remote Patient Monitoring for blood pressure and blood glucose. Monitor patient blood pressure and blood sugar numbers. Communicate with the patient and provider regarding readings.
• Complete outreach calls to patients with suspected medication non-adherence with the goal of improving adherence.
• Complete other interventions to improve medication access and adherence such as prior authorizations, tracking of patients on medication assistance programs and medication refill quality improvement projects.
• Work with the patient, family, and care team to create mutual goals to improve health status.
• Educate patients/family members and use behavior change strategies to improve patient health status.
• Within organizational protocols and nursing scope of practice, assist patients with receiving needed labs, screenings, referrals, other preventative needs, etc.
• Administers intramuscular, subcutaneous, and intradermal injections, including vaccines and prescribed medications, in accordance with clinical protocols and safety standards.
• Performs procedures including, but not limited to, spirometry and diabetic retinal imaging, preparing results for provider interpretation and follow-up care planning.
• Facilitate patient access to internal and external medical and specialty providers.
• Serve as a primary contact, advocate, and educational resource for patients and families.
• Facilitate transition of patients from inpatient and ED.
• Assist providers in women’s health and primary care in handling urgent patient care needs that are above the level of an MA or LPN such as delivering sensitive messages to patients.
• Identify patients to enroll in your case management services by being available to go into exam rooms during provider visits, conducting outreach calls to enroll people, and advocating that providers assist you.
• Participate in Quality Improvement meetings and initiatives.
• Assist in investigating clinical incidents.
• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

Equipment Operated

Telephone & Fax

Computer & Printer

Blood Glucose Monitor

Blood Pressure Machines

Waived function testing

Pulse oximeter

EKG

Centrifuge

NST machine

Oxygen

Audiometer

Audio Visual

HBA1C analyzer

Ultrasound

Other office and medical equipment as assigned

Facility Environment

Heart of Ohio Family Health operates in multiple locations, in the Columbus, OH area. All facilities have a medical office environment with front-desk reception area, separate patient examination rooms, nursing stations, pharmacy stock room, business offices, hallways and private toilet facilities. All clinical facilities are ADA compliant.

This position’s primary work area is the clinical portion of the facility; ie, patient examination rooms, hallways, and other clinically assigned areas.

The clinical area is:

• kept at a normal working temperature
• sanitized daily
• maintains standard environment furniture with adjustable chairs
• maintains standard office equipment; ie, computer, copier, fax machine, etc. at a normal working height

Physical Demands and Requirements these may be modified to accurately perform the essential functions of the position:

• Mobility = ability to easily move without assistance
• Bending = occasional bending from the waist and knees
• Reaching = occasional reaching no higher than normal arm stretch
• Lifting/Carry = ability to lift and carry a normal stack of documents and/or files
• Pushing/Pulling = ability to push or pull a normal office environment
• Dexterity = ability to handle and/or grasp, use a keyboard, calculator, and other office or medical equipment accurately and quickly
• Hearing = ability to accurately hear and react to the normal tone of a person’s voice
• Visual = ability to safely and accurately see and react to factors and objects in a normal setting
• Speaking = ability to pronounce words clearly to be understood by another individual

Job

Qualifications (Experience, Knowledge, Skills and Abilities)

Education: Bachelor's degree in nursing.

Experience: 0-3 years clinical care experience. Ambulatory or primary care nursing preferred. Hospital-based nursing acceptable. Ideal candidate has case management experience and experience working with patients with chronic diseases or complex health issues. Candidates must have valid driver’s license, reliable transportation, and maintain CPR certification.

Registration/Licensure: Current RN License