In collaboration with patients, families (as defined by the patient) and staff across Program Specific disciplines and departments is responsible for managing all aspects of patient-centered care for patients with chronic illness. Works closely with the patient, the caregivers, physicians, and interdisciplinary health care teams to provide long-term care coordination and cost management for patients with chronic illness.

ESSENTIAL/PRIMARY DUTIES

• Assess the state of patient and primary caregiver by conducting comprehensive interviews with patient and caregiver, specific to assigned Program.
• Develop and communicate (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice (for chronic illness) for designated target population per Program guidelines.
• Monitor the patient’s condition on a regular basis or as indicated in Program guidelines.
•  Manage and coordinate all transitions between sites and providers of care or as indicated in Program guidelines.
• Educate and support the patient (family caregivers) as per Program guidelines.
• Facilitate patient access to community services.
• Provide direct nursing care to patients as indicated in Program guidelines, including Program specific SDO’s, and distribute medications and treatments according to accepted standards of care as applicable.
• Patient triage as needed.
• Optimize patient outcomes through the coordination of care with other providers by ensuring that patient care plans are in place.
• Proactively manage and follow-up with patients according to the specified care plan.
• Complete all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
• Attend daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions.
  • These may be related to quality assurance, patient care and other related topics within the clinic.
• Oversee assigned staff, including but not limited to, establishing work assignments, weekly review and adjustment of timecard, weekly review of time off requests, input for performance evaluations, monitoring orientation of new hires, and coaching and counseling staff in conjunction with Director of Population Health.
• Provide coaching/mentor of Staff Development of assigned staff.
• Along with Triad team, participates in quality strategies to evaluate compliance with evidence‐based guidelines, standards, and to identify opportunities to improve patient outcomes.
• Attend seminars and maintain all licensure and/or certification requirements for continuing education and best practices.
• Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
• Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard
• Operating Procedures and CommUnityCare Policies and Procedures.
• Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff.
• Interact respectfully and collaboratively with patients and their families, striving to develop favorable relationships with families.
• Collaborate with all members of the care team in providing patient-centered care.
• Adhere to program and/or grant specific guidelines, goals, and objectives, including obtaining data and achieving metrics as required.
• Direct outreach and facilitating access to medical care via alternate methods, such as street medicine or designated health clinics.
• Work with patients, staff, and other members of the interdisciplinary team in the field, which can include parks, campsites, and other known places of habilitation for homeless individuals, and provide direct patient care and/or interventions as appropriate.
• Coordinate and participate in patient outreach efforts to facilitate enrollment into grant funded support program utilizing appropriate tools, such as but not limited to IDDT (Integrated Dual Diagnoses Treatment) methodologies.
• Perform other duties as assigned.

Knowledge/Skills/Abilities:

• Provide coaching/mentoring of clinical staff.
• High level of skill at building relationships and providing excellent customer service.
• High degree of knowledge and competency in the practice of medicine and associated charting requirements.
• Requisite skills and ability to perform certain medical tasks as assigned.
• Experience managing difficult patient/customer situations.
• Demonstrate success in directing staff in order to achieve a common goal.
• High level of problem solving skill to better serve patients and staff.
• Strong attention to detail and accuracy.
• Excellent verbal and written communication skills.
• Ability to travel frequently to hospitals or other sites where patients are receiving care.
• Demonstrated success in the delivery of quality nursing practices and duties assigned to this role.
• Demonstrated experience managing multiple nursing activities at once.
• Demonstrated experience with direct patient services and the proper knowledge and use of medical devices and equipment.
• Demonstrated familiarity with tools, technology, and systems typically found within most health care environments (i.e. personal computer skills, spreadsheets, word processing, patient records systems, EMR systems, etc.)

EDUCATION:

• Graduation from an accredited school of nursing required.
• Bachelors of Science in Nursing preferred. 

EXPERIENCE:

• Minimum of 2 years of clinical nursing experience required.
• Working with special patient populations, such as but not limited to LGBTQIA, HIV, homeless, mental health, or substance use disorders preferred.
• Two (2) years of experience in a supervisory role preferred.

CERTIFICATIONS/LICENSURE:

Current license to practice nursing in the state of Texas required.

REQUIRED COURSES/COMPLETIONS (e.g., CPR):

• Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross required upon hire.
  • Will be required to maintain a current CPR certification during employment.