Website St. Croix Regional Family Health Center
Position Summary: The RN – Triage / Care Manager is a practice-based RN who directly supports SCRFHC’s highest risk patients with the primary responsibility to direct the daily clinical support staff activities towards the provision of safe, high quality and efficient primary care to a patient population diverse in age, health status, and socio-economic level. In collaboration with other members of the healthcare team, the RN – Triage / Care Manager is responsible for triaging, organizing, coordinating, providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor outcomes.
This position requires strong leadership and communication skills, nursing experience with an strong knowledge base in family medicine/primary care nursing.
The RN – Triage / Care Manager communicates with patients to assess their needs, follows triage or health center care protocols and when indicated, consults with health professionals to decide on which services to provide. Responsibilities include planning, organizing, and informing patients regarding general preventative and basic acute care practices as well as individualized care plans. Work involves using health information technology to keep track of patients’ records, especially electronic records, and must keep current with computer technology, software, security measures, and legislation regarding patient privacy and other issues.
Work in a manner that supports the mission and purpose of the health center and performs in accordance with system-wide competencies and behaviors, utilizing both the Patient Centered Medical Home model and the Accountable Care Organization measures. Duties are performed under the general supervision of the Medical Director but routinely reports to the Quality Director.
- Monitors and responds to triage calls in person and/or on the nurse phone line.
- Talks directly to patients on the telephone and then directs them to emergency rooms (ERs), urgent care centers, and home care advice or to schedule patients to their physician during office hours.
- Determines urgency of seeing the patient based on brief assessment and on familiarity with a patient’s condition and history.
- Uses computerized clinical decision-making including algorithms that closely imitate physician logic and thought patterns, as guide.
- Sends patients with high-risk chief complaints such as chest pain, abdominal pain, or severe headaches to ER immediately or arranges for ambulance.
- Provides appropriate home health advice to patients who do not need to go directly to the ER.
- Ensures accurate notes of all consultations and treatments are recorded in the patients’ record.
- Arranges appointments for patients who do not need to go to ER but need to see a physician. Consults with physician as needed.
- Acts, when designated, in “Ask a Nurse” capacity, handling routine information requests from patients, e.g., “Do I need a flu shot every year? When are you giving these shots?”
- Serve as a clinical resource and professional role model for other nursing staff.
- Prioritizes work tasks and services and completes tasks in a timely manner.
- Assist in medical chart reviews and compiling data for audits and reports.
- Assist Managing Nurse with developing nursing policies and procedures.
- Maintains accurate, clear and concise progress notes, problem lists, and medication lists.
- Provides patient education regarding disease processes, therapies and healthful behaviors.
- Communicates appropriately and tactfully with staff, consultants, patients, significant others, and community.
- Reduce conflict and increase patient satisfaction whenever possible through timely response to calls.
- Participates in staff, planning, in-service, and other meetings as needed.
- Administers medications and performs medical and nursing procedures as ordered within the scope of practice.
Care Management Systems:
- Manage SCRFHC high-risk patient registry
- Oversee systems for identifying high risk patients through EMR, referrals, registries from health insurance payers
- Ensure validity of registry; collaborate with Information Technology on registry functionality.
- Develop a tracking system for patient care coordination and care management across the continuum, including care transitions, Primary and Specialty care.
- Act as clinical liaison for Payer Based Care Management programs, including ACO, commercial payors, Medicare advantage, managed care and Medicaid as indicated.
- Conduct data reporting to identify gaps in care or services and conducts patient outreach to facilitate follow-up care or services.
- Visit, educate, and serve as a resource to providers on patients with chronic and/or high-risk conditions that could benefit from extra services to provide coordination and linkage to general medical services.
- Communicate and coordinate with medical and mental health providers concerning options, including community services; available to the patients they serve.
- Meet with patients, primary care and behavioral health providers, and other staff as needed to develop and coordinate treatments plans; meet with patient family members as needed.
- Interface with and refer patients to other supportive services as appropriate.
- Serve as a linkage between SCRFHC providers and other providers that the patient is seeing to improve coordination of services and information flow.
- Provide self-management support to patients. Work to educate, motive, and coach patients utilizing disease-specific protocols.
- Provide patient education sessions for various health conditions, e.g., diabetes, CHF, COPD, etc.
- Provide ongoing phone contact with patients.
Direct Patient Care: (when indicated)
- Provide direct nursing care as indicated and/or provide nursing back-up in the event of staff shortage, including provision of telephone triage and provider assistance and support.
- Participate in and direct nursing care including but not limited to Annual Wellness Visits
- Provide nursing back-up in the event of staff shortage, including provision of telephone triage and provider assistance and support.
- Escort patients to exam room and prepare patients for exam.
- Take and record vital signs, patient histories, and other pertinent information.
- Prepare patients and assist providers with procedures. Prepare instruments.
- Administer immunizations, medications, and monitor patient response to these agents.
- Provide patient education as directed by providers
- Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of ED visit notification.
- Conduct comprehensive assessment of patients’ physical, mental, and psychosocial needs
- Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ED utilization
- Utilize behavioral strategies help patients adopt healthy behaviors and improve self-care in chronic disease management. Promote self-management goals.
- Assist patients in navigating the health care system. Coordinate Specialty care, follow-up on test results and other care coordination needs.
- Partner with external case management programs to coordinate care
- Ongoing evaluation and documentation of patient progress / risk status in EMR and communicate with care teams
- Document all patient related activity in EMR, per policy
Patient-Centered Medical Home:
- Pro-actively support PCMH initiatives related to care coordination.
- Participate in Quality Improvement Committee activities, trainings, and participate in professional development activities
- Pro-active member of care teams in team-based care initiatives
- Practices team-based care
- Involved in huddles on daily basis per huddle procedure
- Stay up to date with trends in healthcare to develop/ revise integrated care management programs
- **Perform other duties as requested or assigned.
- Valid RN licensure. 3-5 years of relevant experience preferred.
- Experience working in triage, case management, disease management, home health care nursing, hospital nursing or intensive outpatient education and/or self-management support skills
- Ability to work with a variety of people from different professions
- Relationship building with patients, staff, and providers
- Comprehensive nursing assessment, problem identification and care plan development
- Disease management
- Ability to interact with physicians and other health care professionals in a professional manner.
- Working knowledge of physical health and behavioral health medications.
- Screening for developmental issues, depression, other psychological conditions, and frailty.
- Behavioral strategies including motivational interviewing and self-management support
- Ability to communicate effectively orally and in writing
- Ability to initiate and implement procedures and to evaluate their effectiveness
- Ability to use a personal computer or computer terminal
- Visual/hearing ability sufficient to comprehend written/verbal communications and work with documents and reports.
- Ability to travel to required meetings and conferences.
- Clinical system design and development
- Project and time management skills
- Solid computer skills including excel, word, and PowerPoint.
- Organized and resourceful self-starter; strong ability to work in a team
- Excellent written, oral, and interpersonal communication skills
- Working conditions: primarily office-based, with the ability to do home visits on a limited basis
Required Screening: All potential new employees will undergo a background and Office of Inspector General exclusion report and periodically thereafter. All employees must provide a Statement of Health, signed by their primary care provider, be fully vaccinated for COVID-19 and provide vaccine records for other mandatory vaccines
- All new employees must complete all mandatory trainings, communication training, Health literacy and patient safety, within the first week of employment.
- All new employees must complete training in coordination of care for patients and maybe assigned to a care team to support patients and families in self-management, self-efficiency, and behavior change within the first 2 weeks of employment as administered by leadership.
- All new employees must complete training in population management within the first month of employment as administered by leadership.
- All clinical employees must complete at least basic motivational interviewing training within 3 months of employment.
SCRFHC is an Equal Opportunity Employer, M/F/D/V are encouraged to apply
To apply for this job email your details to firstname.lastname@example.org