Job Description

This role works with a dedicated Primary Care Provider and supports primary care activities for the PCP panel, including patient education, orders, referrals, and medication management, and addressing gaps in care. The Team Nurse works directly with members to achieve their care plan goals through patient education, care coordination, and building relationship.

Duties and Responsibilities

• Act as the practice-based nurse, supporting on-site providers in facilitating high quality primary care that promotes appropriate healthcare utilization.
• Facilitate Patient Centered Medical Home (PCMH) functions through management of diagnostic order tracking, medication refills, review of the medical record, and fielding messages from members and the integrated care team.
• Lead panel management for members attributed to the assigned primary care provider through activities including, but not limited to, following disease care pathways, entering standing orders for preventive care, and leveraging available reports to close care gaps.
• Monitor access to the primary care provider. Ensure members have scheduled follow-up.
• Coordinate services to complete primary care provider action plan tasks.
• Meet with members in the medical center as an extension of the primary care provider to address member needs, including medication reconciliation and teaching and coaching for effective disease management.
• Engage members telephonically between primary care visits to support PCMH activities, panel management, and action plan completion.
• Prepare for and participate in daily huddle with the integrated care team.
• Act as a bridge between the primary care provider and the greater integrated care team. Coordinate internal referrals between team members.
• Coordinate with the Immediate Care Area to provide in person and telephonic triage. Perform nursing interventions including wound care, IV (intravenous) therapy, and phlebotomy as needed.
• Provide coverage support for fellow care team members as needed, including point of care testing, medication administration, and office flow.
• Leverage strong time management skills to prioritize and balance member care responsibilities with provider panel management and role-specific tasks.

Minimum Qualifications

• Active, unrestricted license as a Registered Nurse in the state of practice required. Compact RN license preferred, or willingness to obtain.
• 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions.
• Active CPR certification.
• Experience working for a community-based organization preferred.
• Proficiency in clinical nursing skills such as wound assessment and care, venipuncture and phlebotomy, and assessment and management of common chronic conditions such as diabetes, hypertension, CHF, and COPD.
• Excellent interpersonal communication, problem solving, and organizational skills.
• Independent self-starter and critical thinker interested in population health, healthcare utilization management, and the ongoing development of our care model.
• Proficiency with Microsoft Office applications.

Working conditions

This job operates in a professional office environment. This role routinely uses general office equipment. Often wear a special uniform, such as a lab coat or surgical scrubs, protective or safety attire, such as gloves and masks. Exposed to the diseases and infections of patients daily. May share workspace with other technicians and staff.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.