A Registered Nurse provides medical care and treatment, educates patients about their conditions, and provides emotional support to patients and families. Works in hospitals, schools, clinics or community health centers. Works under the supervision of a physician or other specialist, and serves as the primary point of care for patients in a hospital setting. May specialize in emergency room work, or treatment for a particular condition, or specialize in working with infants, the elderly or other patient groups. May work as an advanced practice specialists and prescribe medications in addition to offering specialty care.
The Registered Nurse (RN) or Licensed Practical Nurse (LPN) supports the Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) Programs by providing ongoing care coordination, patient outreach, documentation, medication reconciliation, and communication with patients, caregivers, providers, pharmacies, specialists, hospitals, and community resources. The nurse assists in ensuring patients with chronic conditions receive comprehensive, coordinated care while supporting program compliance, quality outcomes, and reimbursement goals.
Responsibilities:
Chronic Care Management Activities Document all
CCM/APCM
activities in the Electronic Medical Record (EMR) in accordance with CMS guidelines. Accurately track and record CCM time. Assist in identifying patients eligible for
CCM/APCM
enrollment. Review prior
CCM/APCM
documentation to ensure continuity of care and avoid duplication of services. Assist with annual and interim updates of individualized patient care plans. Care Coordination Provide support for patients transitioning from hospitalizations or other acute settings. Ensure all
APCM/CCM
patients have a personalized care plan that addresses their unique needs, preferences, and goals, including medication management, health education, lifestyle modifications and specialist coordination. Follow up on referrals, diagnostic testing, and specialty consultations. Clinical Review and Documentation Review medical records for gaps in care and preventative health needs. Reconcile medications utilizing Medication Administration Records (MARs), and provider documentation. Update problem lists, diagnoses, allergies, immunizations, and patient demographic information as appropriate. Assist with documentation required for quality measures and value-based care initiatives. Quality and Compliance Participate in audits and quality improvement initiatives. Monitor and evaluate the effectiveness of the
APCM/CCM
program, using data and metrics to assess progress toward goals. Ensure that all work performed under the
APCM/CCM
program is meaningful, high-quality and compliant with relevant regulations and standards. Collaboration and Creativity Work collaboratively with providers, medical assistants, patient representatives, nursing staff, and administrative personnel. Applies critical thinking and creativity to develop innovative approaches to care management. Foster a patient-centered culture that prioritizes quality, compassion, and continuous improvement. Assist the CCM Coordinator in achieving monthly program goals and improving patient outcomes. General Provides care in a non-judgmental, non-discriminatory manner that is sensitive to the patient's and family's diversity, preserving their autonomy, dignity and rights. Completes assignments as requested by supervisor.
Qualifications:
Graduation from an accredited Bachelor of Science in Nursing (BSN) program and an active Registered Nurse (RN) license, required; or High school diploma or equivalent (GED) and graduation from an accredited Licensed Practical Nurse (LPN) program, required. Excellent verbal and written communication skills-Strong organizational skills Strong documentation and computer skills. Strong Commitment to the provision of quality medical care for medically underserved individuals. Ability to work independently while managing multiple priorities. Proven capacity to work productively in highly collaborative settings and to seek and synthesize input from multiple stakeholders. Minimum one year of nursing experience preferred Experience working with individuals with Intellectual and Developmental Disabilities (I/DD), including coordination of medical, behavioral health, residential, and community-based services, strongly preferred. Experience in primary care, case management, care coordination, population health, or chronic disease management preferred. Knowledge of Electronic Medical Records (EMR) systems. Preferred Skills Strong oral, written, and organizational skills required. Prior experience coordinating medical record activities of a busy medical office or healthcare center, a plusPhysical Requirements Physical Requirement Prolonged periods of sitting and computer work. Monday through Friday, as assigned. Flexibility to work in both health centers as assigned. Role can be done as hybrid, in-person, remote basis on needs of health center.
