Registered Nurse

Job Responsibilities

• Identify patients with high risk for adverse health outcomes, establish relationships with these patients to enable effective intervention and support.
• Create goals with patients and develop plan of care.
• Identify barriers of care to high risk patients, implement care plans with patients to provide self-management and support interventions.
• Optimize patient access to needed services through insurance and other benefits.
• Facilitate effective transition of care through the provision of comprehensive follow up to in-patient and skilled nursing admission when discharged home.
• Provide patient education in regard to discharge instructions and medication questions.
• Promote health maintenance in high risk population patient panel, and participate as a member of the Care Team.
• Work with outside agencies and providers to share patient information for best health outcomes.
• Assess incoming phone calls and walk-in patients needing triage.
• Assess and provide follow up for patient ED and UC visits.
• Assist in population health efforts focusing on preventative care and chronic condition management.
• Monitor patients on chronic anticoagulation therapy.
• Work in RN capacity to facilitate community outreach efforts such as vaccine clinics and direct patient care in the clinical setting.
• Provide culturally competent interventions based on patient assessment and identified cultural needs.
• Perform other duties as assigned.

Requirements

Skills / Qualifications: Excellent communication skills and ability to form collaborative partnerships across all service settings Working knowledge of the provision of health care in a variety of settings Knowledge of community resources preferable Ability to engage and build relationships with patients Ability to prioritize workload and assess the need for collaboration with the health care team Basic computer literacy skills, with competence in Microsoft Office products such as Work, Excel, Outlook and PowerPoint, and experience working in an electronic health record (EHR) Ability to assimilate new information and technologies into daily work Bilingual desired but not required Flexibility in schedule – some evenings and weekends may be required Education/Experience: Graduate of an approved school of nursing with RN license to practice in NYS. Must maintain a current and valid registration certificate 2-3 years’ experience in Primary Care, inpatient or outpatient Internal Medicine/Family Medicine, Public Health, Case Management, or related field preferred. Current certification in Basic Life Support for Healthcare Providers or equivalent Organization Wide Responsibilities: · Participate in OOH efforts to provide the highest quality patient care to all segments of the communities we serve · Provide all patient care with mindfulness of the Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. · Handle confidential information in accordance with HIPPA as well as state and federal privacy and confidentiality rules · Comply with organizational policies and procedures · Attend team meetings, trainings, ongoing skill development events and other functions as required Comprehensive Benefits: Health / Dental /Vision Insurance Retirement Plan Tuition Reimbursement Public Service Loan Forgiveness Generous Time Off