RN/LPN Care Coordinator

About Us:

Neighborhood HealthSource provides quality primary care, community health, & behavioral health services in North & Northeast Minneapolis & Coon Rapids. We work with individuals & families across the lifespan with the mission of increasing access to quality care for all who need it. It is the mission of Neighborhood HealthSource to improve the health of our communities by providing quality healthcare services that are affordable and accessible while advancing health equity for all. What does our mission look like in action? We envision a community in which cost is never a barrier to access, where every person can access comprehensive health care from compassionate, qualified, well-trained, and respectful staff, where everyone honors diversity and culture, and where health equity is achieved.

Overview:

The RN/Care Coordinator works in collaboration and continuous partnership with patients and their family/caregiver(s), hospitals, specialty providers and staff, and community resources in a team approach. The RN also provides supportive functions to NHS providers,

Essential Functions & Responsibilities:

General Nursing:

• Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
• Handles incoming triage calls: (LPN under the supervision of RN and Medical Director)
• Provides appropriate patient education regarding medical condition
• Provides medication instructions
• Supports providers by following up with patients regarding their lab/imaging results as guided by the provider
• Documents telephone discussions in the patient's electronic medical record (EMR)
• Handles incoming Nursing Home Orders
• Handles incoming pharmacy questions, clarifications and prior authorizations
• Calls patients with medication changes, directions and education, as ordered by providers
• Provides nursing support, when needed, to the RNs and NHS providers
• Utilizes the Patient Portal to communicate with patients
• Sees patients on daily nurse schedule:
• Responds to the needs of walk-in patients
• Assists providers and clinic RNs as needed
• Provides (RN) or reinforces (LPN) education on medical condition, e.g., asthma, diabetes, family planning
• Reads and documents PPD results
• Provides refill requests that come through the EMR, phone or fax
• Reconciles medications
• Maintains an emergency box of medications
• Oversees the application/enrollment and tracking process for patients in indigent medication programs
• Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency (RN only)
• Provides community-based nursing care as established by the organization, as requested

Care Coordination/Case Management Support:

• Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:
• Assists with the identification of "high risk" patients (those with chronic illness and/or special health care needs)
• Contacts patients to enroll them into HCH and documents patient's acceptance or declination, to populate the registry
• Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care and educates patients on when to utilize the ER
• Reviews FUHN/ID Stratification patient's EMR to see what patients may need; refers to specialty providers and to help with medication reconciliation
• Works with patients to plan and monitor care:
• Assesses patient's unmet health and social needs
• Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
• Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed
• Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire
• Facilitates patient access to appropriate medical and specialty providers
• Educates patient and family/caregiver(s) about relevant community resources
• Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals
• Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider
• In collaboration with the primary care provider, assigns the appropriate tiering level based on required criteria for HCH patients
• Advocates for the participant in understanding needs surrounding transportation, shelter, child care and safety. Refers participant to behavioral health services if warranted
• Keeps EMR care plans updated for easy access by HCH Team
• Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox messaging and/or team huddles to update and advance care coordination within the Team
• Utilizes all available tools to deliver education, instruction, care coordination and training, including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies & procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease management brochures; disease management participant tracking records (Diabetes glucose records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific educational handouts; services offered by NHS

Core Requirements:

• Works collaboratively and respectfully with staff and others—individually and as part of a team—to achieve optimal efficiency, outcomes and morale
• Interacts in a culturally competent manner with individuals and groups from diverse backgrounds, including but not limited to: socio-economics, race and ethnicity, nationality and religion, both in-clinic and in the community
• Maintains excellent and punctual attendance
• Attends and actively participates in staff and departmental meetings
• Attends agency functions and meetings as relevant or required
• Works at any or all NHS clinics, as needed
• Uses computer daily including e-mail, word documents, spreadsheets, patient management system, electronic health record, and patient portal, as needed to carry out essential job functions
• Maintains any required licensure/certification
• Demonstrates commitment to agency mission and goals
• Abides by corporate compliance program, HIPAA regulations and other agency policies and procedures
• Participates daily in pre-visit planning and huddles (RN/LPN, Provider, Medical Assistant, Front Desk)
• Plans, organizes, and multitasks
• Speaks, understands, reads and writes English sufficiently to carry out all essential duties
• Performs other duties as assigned

Qualifications:

• Graduation from an accredited nursing program
• Current Minnesota RN/LPN license/certification
• Minimum one year experience in a primary care setting preferred
• Patient education experience
• Family planning experience highly desired
• Motivated to improve the health of the community
• Excellent interpersonal communication

Benefits: Neighborhood HealthSource offers competitive pay and benefits among community health centers. Eligible employees (24 hours/week or more) receive benefits including:

• Generous paid time off and holidays
• Health insurance
• Life insurance
• Disability insurance
• Flexible spending