Medical Chronic Care Management Nurse

Medical Chronic Care Management Nurse La Conner, WA 98257 $53.61 - $68.22 an hour - Full-time $53.61 - $68.22 an hour - Full-time Job Summary The Chronic Care Management Coordinator supports the mission of the Swinomish Health System by improving health outcomes for patients living with chronic conditions such as diabetes, hypertension, kidney disease, and other ongoing health concerns. This position also oversees patient registries and preventive health screening initiatives. The ideal candidate will have experience in population health management, electronic health records (EHRs), patient care coordination, and chronic disease management. In addition to maintaining health registries and clinical documentation, this role works directly with patients to provide education, health coaching, self-management support, and care coordination in collaboration with primary care providers, clinical pharmacists, social workers, and other members of the care team . Essential Job and Responsibilities Develop and manage population health registries using electronic health records and other health management tools to monitor chronic care metrics and preventive screening measures. Design, implement, and report on outreach activities aimed at improving chronic disease management and preventive health outcomes. Collaborate with the Chief Medical Officer or designee to develop clinical workflows and strategies that ensure patients receive appropriate chronic disease and preventive care during office visits. Provide comprehensive chronic disease management services, including patient education, counseling, and coordination of care. Work collaboratively with interdisciplinary team members to support patient outreach, engagement, and follow-up care. Advocate for patients and families by connecting them with entitlements, community resources, and support services. Partner with primary care providers and clinical pharmacists to develop integrated, patient-centered care plans and communicate goals and treatment recommendations with patients and families. Obtain and document relevant health histories; monitor patient progress; and support implementation and adjustment of treatment plans as appropriate. Maintain accurate and timely documentation of clinical activities, including problem lists, medication and allergy information, and treatment plan recommendations. Participate in quality assurance and quality improvement initiatives. Attend multidisciplinary meetings and provide nursing-related input regarding patient care and treatment planning. Serve as an educational and consultative resource for medical staff, pharmacy staff, and other team members regarding patient registries and chronic care management processes. Assist in developing guidelines and best practices for chronic care management services. Prepare reports, data summaries, and proposals as requested by healthcare leadership. Provide backup support to medical assistants and registered nurses within the applicable scope of practice, including: Rooming patients Taking vital signs Administering vaccinations Performing phlebotomy Conducting point-of-care testing Perform other duties as assigned Minimum Qualifications Graduation from an accredited Registered Nursing program and a minimum of two (2) years of clinical experience required, OR LPN or Medical Assistant-Certified with 8-years of directly relevant experience. An active Washington State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Medical Assistant-Certified (MA-C) is required. Valid Washington State driver's license required. Current BLS/CPR certification required. High proficiency in Microsoft Excel and/or other database software required. Experience working with American Indian/Alaska Native (AI/AN) communities preferred. Required Knowledge, Skills, and Abilities Knowledge of chronic disease management, preventative care, and population health practices. Knowledge of electronic health records (EHR) systems and clinical documentation standards. Strong care coordination, patient education and health coaching skills. Effective communication and collaboration skills with patients, families, and interdisciplinary teams. Proficiency with Microsoft Excel, databases, and healthcare technology systems. Ability to organize, track, and manage multiple patient care priorities and follow up activities. Ability to analyze data, identify care gaps, and support quality improvement efforts. Ability to maintain accurate records, protect patient confidentiality, and exercise sound professional judgement. Ability to work independently and collaboratively in a fast-paced healthcare environment Ability to provide culturally responsive care and build positive relationships with patient population. License and Certificate Requirements Valid WA State Driver's License An active Washington State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Medical Assistant-Certified (MA-C) is required.

Pay:

$53.61 - $68.22 per hour

Benefits:

401(k) 401(k) matching Dental insurance Disability insurance Employee assistance program Flexible spending account Health insurance Life insurance Paid sick time Paid time off Parental leave Vision insurance

Work Location:

In person