The Nurse Patient Care Coordinator/Educator supports patients with complex chronic illnesses by coordinating care, educating them on self-management, and building trust between patients and practitioners. This role involves conducting monthly face-to-face patient encounters, assessing needs, providing educational interventions, and monitoring health status changes.
Requirements summary
Candidates must possess either an Associate's or Bachelor's Degree in Nursing with 3 years of chronic disease management experience and SC RN licensure, or a Practical Nursing Degree with 5 years of related experience and SC LPN licensure. Experience in patient education and chronic disease management is required, with a BSN or post-graduate care management training being preferred.
associate degreebachelor degreepostgraduate degreeCommunicationAssessmentCounselingPatient EducationInterdisciplinary Team CollaborationTriageHealth MonitoringPatient Care CoordinationRN LicensureEHR DocumentationDisease ManagementPreventive CareChronic Disease ManagementLPN LicensureHealth Care Resource AccessBehavioral Change Goal-Setting
Job description
JOB SUMMARY The NPCC/E works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illness. This position supports improvements in health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. The NPCC/E will teach, counsel and monitor patients on issues relevant to their health. As a member of an interdisciplinary team, this position will consult with other health care team members to coordinate the provision of patient education, preventive care and disease management.
Duties
Performed
Ryan White NPCC/E: complete and document a minimum of 50 face-to-face patient encounters each month.
Assess cognitive/verbal skills and identify barriers to accessing healthcare.
Provide individual and family educational interventions including self-management goal-setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease.
Perform individualized assessment of a patient’s educational needs and provide tools to aid in managing their disease(s) effectively.
Provide individual counseling on office procedures, eligibility for programs/services, importance of a primary care medical home and other health issues.
Monitor patients for changes in health status after initiation of a new medication, a hospitalization or recent decline in function.
Follow-up with patients when barriers to referrals are identified.
Monitor lifestyle factors affecting health – such as tobacco use, substance abuse, nutrition and physical activity – and assist the patient with goal-setting to achieve behavioral change.
Document assessments, education, goals, outcomes and updates in the patient’s EHR for review by their practitioner.
Participate in staff meetings focused on coordinating patient care within an interdisciplinary team, keeping the team updated on a patient’s condition and circumstances.
Triage and facilitate response to urgent telephone calls, requests or visits from assigned patients
Requirements
Basic requirements:
Associates or Bachelors Degree in Nursing and 3 years work experience related to chronic disease management and licensure as an RN in South Carolina or, Practical Nursing Degree, 5 years work experience related to chronic disease management and licensure as an LPN in South Carolina
Benefits
Paid Holidays
Medical
Dental
Sick leave
Flexible Spending Accounts
Retirement Plan
Employee discounts
Short Term Disability
Long Term Disability
Voluntary Life Insurance
Health Savings Accounts
Vision benefits
Bonuses
Annual Leave
Public Service Loan Forgiveness Program
Continuing education courses
Accident and Critical Illness Coverage
Experienced in patient education and/or chronic disease management
Preferred requirements:
BSN Degree in Nursing
Post graduate training in care management such as a Certificate in Guided Care Nursing or ANCC certification in Case Management Nursing
Experience working in clinical out-patient settings
Experience working with diverse population groups
Content knowledge and expertise in program-specific field
Benefits
and Perks: New Horizon Family Health Services offers a robust and comprehensive benefit package to full time employees.
Automatic:
Annual Leave
Sick leave
Up to 12 Paid Holidays plus your birthday
Eligibility for 2 annual bonuses after 1 year of employment when defined eligibility criteria are met
Continuing education courses through SC AHEC
Various employee discounts. I.e., Verizon, AT&T, YMCA, etc.
Eligibility for the Public Service Loan Forgiveness (PSLF) Program
Optional:
Medical (PEBA State Health Plan), Dental and Vision benefits
Flexible Spending and Health Savings Accounts
Voluntary Life Insurance
Short Term Disability and Long Term Disability
Accident and Critical Illness Coverage
403 (b) Retirement Plan, with up to 4% employer match after the first year of employment
Mission
Our Mission is to provide quality, affordable, compassionate patient-centered health care to improve the health of the communities we serve. Our Vision is that our community will be one of the healthiest in the Nation. Superior patient care is the hallmark of NHFHS.
ICARE Values
The ICARE values of New Horizon Family Health Services guide our employees toward achieving the mission of our company and our vision for our community. Our values stand for Integrity, Collaborations, Accountability, Respect, and Enrichment.
Community
Greenville, South Carolina is the perfect place to live, work, and play. Greenville is surrounded by mountains, lakes, hiking & biking trails, as well as recreational activities including golf, tennis, water sports, cultural performances and more. Geographically located between Atlanta, GA and Charlotte, NC, with beaches just 3.5 to 4 hours away.
We are an Equal Opportunity Employer.
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