Chcfhc
Greater Gardner
Gardner | GARDNER
175 Connors Street
Gardner, MA 01440, USA
Pay or shift range: $33.50 USD to $41.59 USD
The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.
Description $3,000 sign-on Bonus!
JOIN THE CHC FAMILY!
Community Health Connections (CHC) is a multi-site, non-profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, and substance use disorder treatment, and specialty services including optometry eye care, optical shop, acupuncture, nutrition consultations and podiatry. CHC is mission-driven, providing compassionate, quality health care regardless of income or health insurance status. CHC has five sites within Fitchburg, Gardner and Leominster with decades of experience as a Federally Qualified Health Center (FQHC), serving 36 communities in North Central Massachusetts.
The Care Coordinator performs an integral role in the team-based approach to care, developing collaborative relationships with providers, patients and their significant others and other members of the care team. He/she ensures that high risk patients receive care that is consistent with national, state and health center standards and policies. The Care Coordinator supports patients and families in self-management, through evidenced-based approaches as appropriate, engages in health center projects aimed at specific patient population needs, and utilizes effective and appropriate communication strategies for issues such as health literacy and cultural norms when working with patients. The RN Care Coordinator partners with Care Coordination Specialists and interpreters to ensure that patients are able to access culturally and linguistically appropriate services in a timely and cost effective manner. He/she participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
Essential Duties and Major Responsibilities
Completes an initial assessment actively involving the patient to determine care coordination needs.
Utilizing motivational interviewing techniques, creates and updates care plans which address identified needs and emphasizing patient specific goals and self-management as they relate to desired medical outcomes. Partners with patient to encourage active participation in identifying patient’s own goals.
Utilizes a collaborative approach with the PCP and other team members in creating the comprehensive action plan to help ensure that the patient receives a consistent message from all team members.
Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s/families' level of independence in navigating the healthcare system at all levels of the continuum.
Plans, coordinates, monitors and evaluates progress toward meeting goals in the plan of care.
Serves as a liaison and patient advocate between the providers, health center, and community resources to facilitate access to services and improve the quality of the services delivered.
Educates patient on and/or assist with establishing advanced directives.
Integrates the patient/family members into care coordination and care management planning and communications, assuring the patient/family are informed and supported in decision-making.
Provides ongoing verbal and written communication of patient’s needs, plan of care, progress and changes in status with the PCP, team and the patient/family through comprehensive physical, mental and psychosocial assessments.
Executes medical orders for specific drugs, treatments, and other diagnostic or therapeutic procedures.
Administers and records medication administration consistent with his/her knowledge of pharmacology in accordance with health center policy.
Administers routine vaccines when not administered as part of office visits. Knowledgeable of current and catch‑up vaccine schedules & complies with vaccine storage guidelines as set by the MA DPH.
Participates in preventive health teaching and education pertinent to procedures being conducted.
Working with the primary care provider and other members of the care team, plans and coordinates related complications for the transition care of patients discharged from the hospital within 48 hours to prevent readmission.
Under the direction of the PCP, manages tracking systems and care plans for patients admitted to and any other health care facility with the objective of preventing further disease exacerbation, improving ER utilization outcomes, increasing patient engagement in self‑care, decreasing risk status, and minimizing hospital discharges.
Identifies and manages the patient’s primary driver (reason or problem that caused the hospitalization or ER visit) and under the PCP’s direction, assists/coordinates patient care in problem solving issues related to the health care, financial and psychosocial barriers.
Serves as a resource to non‑clinical staff regarding clinical issues (i.e., phone triage).
Attends department meetings and any mandated continuing education/training programs.
Maintains working knowledge of PCMH and the current requirements.
Demonstrates analytic and data management skills using a variety of PC‑based software, including MS Office Word, Excel, and PowerPoint.
Demonstrates understanding and commitment to the mission of the health center, and established CHC values and standards.
Adheres to established organization policies and procedures.
Perform related duties as required and assigned.
Qualifications
Current MA RN licensure as Registered Nurse. Bachelor of Science Nursing preferred.
Experience in health education or care management preferred.
Clinical experience with patients with chronic disease a plus.
Proficiency with Electronic Health Records (EHR).
Bilingual in Spanish or Portuguese a plus.
AHA BLS Health Care Provider certification.
Excellent critical thinking and problem‑solving skills with attention to details.
Demonstrated interpersonal relationship skills.
Demonstrated written and verbal communication skills in English.
Demonstrated ability to work in a fast‑paced medical office environment.
Benefits
401k.
Generous vacation and personal time for eligible employees.
Sick time.
Medical, dental, and vision insurance.
100% paid Life insurance/AD&D.
100% paid Long‑Term disability.
Employee Assistance Program (EAP).
Discounts on travel and entertainment!
Discounts on cell phone service, computer purchases, and more!
College Tuition Rewards/CMEs.
Company Events & Activities (Annual cookout and holiday party, health and wellness events, Lunch & Learn's, team building, and more!).
EyeMed Vision Care Program.
Discounts on gym membership, travel & entertainment tickets, electronics, and more!
Skills —
Behaviors —
Motivations —
Education Bachelors or better in Nursing.
Experience —
Licenses & Certifications
Registered Nurse.
BLS.
Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
#J-18808-Ljbffr
Pay or shift range: $33.50 USD to $41.59 USD
The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.
Description $3,000 sign-on Bonus!
JOIN THE CHC FAMILY!
Community Health Connections (CHC) is a multi-site, non-profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, and substance use disorder treatment, and specialty services including optometry eye care, optical shop, acupuncture, nutrition consultations and podiatry. CHC is mission-driven, providing compassionate, quality health care regardless of income or health insurance status. CHC has five sites within Fitchburg, Gardner and Leominster with decades of experience as a Federally Qualified Health Center (FQHC), serving 36 communities in North Central Massachusetts.
The Care Coordinator performs an integral role in the team-based approach to care, developing collaborative relationships with providers, patients and their significant others and other members of the care team. He/she ensures that high risk patients receive care that is consistent with national, state and health center standards and policies. The Care Coordinator supports patients and families in self-management, through evidenced-based approaches as appropriate, engages in health center projects aimed at specific patient population needs, and utilizes effective and appropriate communication strategies for issues such as health literacy and cultural norms when working with patients. The RN Care Coordinator partners with Care Coordination Specialists and interpreters to ensure that patients are able to access culturally and linguistically appropriate services in a timely and cost effective manner. He/she participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
Essential Duties and Major Responsibilities
Completes an initial assessment actively involving the patient to determine care coordination needs.
Utilizing motivational interviewing techniques, creates and updates care plans which address identified needs and emphasizing patient specific goals and self-management as they relate to desired medical outcomes. Partners with patient to encourage active participation in identifying patient’s own goals.
Utilizes a collaborative approach with the PCP and other team members in creating the comprehensive action plan to help ensure that the patient receives a consistent message from all team members.
Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s/families' level of independence in navigating the healthcare system at all levels of the continuum.
Plans, coordinates, monitors and evaluates progress toward meeting goals in the plan of care.
Serves as a liaison and patient advocate between the providers, health center, and community resources to facilitate access to services and improve the quality of the services delivered.
Educates patient on and/or assist with establishing advanced directives.
Integrates the patient/family members into care coordination and care management planning and communications, assuring the patient/family are informed and supported in decision-making.
Provides ongoing verbal and written communication of patient’s needs, plan of care, progress and changes in status with the PCP, team and the patient/family through comprehensive physical, mental and psychosocial assessments.
Executes medical orders for specific drugs, treatments, and other diagnostic or therapeutic procedures.
Administers and records medication administration consistent with his/her knowledge of pharmacology in accordance with health center policy.
Administers routine vaccines when not administered as part of office visits. Knowledgeable of current and catch‑up vaccine schedules & complies with vaccine storage guidelines as set by the MA DPH.
Participates in preventive health teaching and education pertinent to procedures being conducted.
Working with the primary care provider and other members of the care team, plans and coordinates related complications for the transition care of patients discharged from the hospital within 48 hours to prevent readmission.
Under the direction of the PCP, manages tracking systems and care plans for patients admitted to and any other health care facility with the objective of preventing further disease exacerbation, improving ER utilization outcomes, increasing patient engagement in self‑care, decreasing risk status, and minimizing hospital discharges.
Identifies and manages the patient’s primary driver (reason or problem that caused the hospitalization or ER visit) and under the PCP’s direction, assists/coordinates patient care in problem solving issues related to the health care, financial and psychosocial barriers.
Serves as a resource to non‑clinical staff regarding clinical issues (i.e., phone triage).
Attends department meetings and any mandated continuing education/training programs.
Maintains working knowledge of PCMH and the current requirements.
Demonstrates analytic and data management skills using a variety of PC‑based software, including MS Office Word, Excel, and PowerPoint.
Demonstrates understanding and commitment to the mission of the health center, and established CHC values and standards.
Adheres to established organization policies and procedures.
Perform related duties as required and assigned.
Qualifications
Current MA RN licensure as Registered Nurse. Bachelor of Science Nursing preferred.
Experience in health education or care management preferred.
Clinical experience with patients with chronic disease a plus.
Proficiency with Electronic Health Records (EHR).
Bilingual in Spanish or Portuguese a plus.
AHA BLS Health Care Provider certification.
Excellent critical thinking and problem‑solving skills with attention to details.
Demonstrated interpersonal relationship skills.
Demonstrated written and verbal communication skills in English.
Demonstrated ability to work in a fast‑paced medical office environment.
Benefits
401k.
Generous vacation and personal time for eligible employees.
Sick time.
Medical, dental, and vision insurance.
100% paid Life insurance/AD&D.
100% paid Long‑Term disability.
Employee Assistance Program (EAP).
Discounts on travel and entertainment!
Discounts on cell phone service, computer purchases, and more!
College Tuition Rewards/CMEs.
Company Events & Activities (Annual cookout and holiday party, health and wellness events, Lunch & Learn's, team building, and more!).
EyeMed Vision Care Program.
Discounts on gym membership, travel & entertainment tickets, electronics, and more!
Skills —
Behaviors —
Motivations —
Education Bachelors or better in Nursing.
Experience —
Licenses & Certifications
Registered Nurse.
BLS.
Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
#J-18808-Ljbffr