Registered Nurse Coordinator Chronic Care Management

Overview

Northside Hospital is award-winning, state-of-the-art, and continually growing. Constantly expanding the quality and reach of our care to our patients and communities creates even more opportunity for the best healthcare professionals in Atlanta and beyond. Discover all the possibilities of a career at Northside today.

Responsibilities

OCCUPATIONAL SUMMARY

The physician referral nurse is a vital resource for the community and physicians. Nurses act as the healthcare connection or navigator that connects the community to the needed resources offered by Northside Hospital and community partners. The Chronic Care Management Coordinator will have ongoing training to remain up to date on a variety of clinical issues.

Facilitates advanced management of care to an identified high risk client population. Demonstrates clinical expertise through direct or indirect care. Coordinates chronic care management for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes. As a collaborating member of the health care team provides pre-visit and follow-up direction and support to the patient, family, and health care providers. A large portion of care will be provided telephonically.

 

 

PRIMARY DUTIES AND RESPONSIBILITIES

Participates in clinical quality activities and facilitating implementation of clinical best practices.

Actively manages assigned panel of patients with multiple chronic conditions. This includes: • Developing relationships with patients as an integral team member. • Providing follow-up contact with patients as indicated to ensure compliance with recommendations – medications, preventive screenings, specialist visits, PCP visits, quality measures, etc. • Providing telephone advice per protocol, handling urgent calls and emergent calls. • Assisting patients in setting goals for self-management, teaching them how to do self-management tasks, and reporting abnormal findings to their physician team. • Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments. • Coordinating care with consulting physicians, and community resources

Develops and documents workflow for the chronic care management program and the reporting of outcomes.

Participates in the nursing care related to assessment, promotion, maintenance and restoration of patients’ health and wellness.

Demonstrates excellent customer service skills to provide exceptional patient and family experience.

Qualifications

KNOWLEDGE SKILLS AND ABILITIES/LICENSE OR CERTIFICATION REQUIRED

Must be a graduate of an accredited school of nursing

Licensed as a RN in the State of Georgia in good standing without limitations.

Must hold Certified in American Heart Association’s Basic Cardiac Life Support (BLS).

Three (3) years of experience as a Registered Professional Nurse (RN).

Ability to relate well with hospital managers, physicians, and office staff.

 

KNOWLEDGE SKILLS AND ABILITIES/LICENSE OR CERTIFICATION PREFERRED

Knowledge of Northside Hospital's medical staff and management team.

Work Hours:

7:00am-4:00pm

Weekend Requirements:

No