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Munson Medical Center Care Team Nurse in Grayling, Michigan

Job Summary: The Care Team Nurse (LPN/RN) is part of a multidisciplinary patient-care team providing and coordinating medical care in an outpatient setting following a patient-centered model. Job duties include accountability for ensuring that the physician/mid-level practitioner is focused on “provider level” work leading to increased face time with the patient. Supports to 2-3 Provider/Care Teams. Facilitates all aspects of the patient visit experience, including but not limited to: provides patient care for acute and chronic medical conditions in collaboration with providers; patient education; phone and walk-in triage; Population Health management; quality improvement activities; and provider inbox/PAQ management. This position is the lead for the Medical Assistants and LPNs within the care team with responsibilities that include providing continuous assessment, training and mentorship to those individuals.

Minimum RN requirements:

Graduate of an approved accredited registered nurse (RN) program. Associates degree in nursing. Current RN license in the State of Michigan, in good standing. Current BLS certification or recertification within 3 months of hire.

Minimum LPN requirements:

Graduate of an approved accredited LPN program. Current Practical Nurse license in the State of Michigan, in good standing. Current BLS certification or recertification within 3 months of hire.

Skills, Talents and Abilities: Effective verbal, written, and interpersonal communication skills with the ability to comfortably interact with diverse populations. Ability to work collaboratively in a team-oriented environment with a strong customer-service orientation. Ability to handle patient and organizational information in a confidential manner. Assertiveness, organizational skills, effective time management, flexibility and self-motivation are essential.

Must have good working knowledge of computer systems with emphasis on Word, Excel, and other programs related to the position. Possess the basic business office skills with emphasis on telephones, computers, and fax and copy machines. Experience using EMR, NextGen and the ability to type at least 30 wpm is preferred.

Position Accountabilities:

  • Provides nursing care, including patient education, assessments, nursing intervention, medical case management and procedures.

  • Develops and implements plans on assessing needs of patients with complex medical and social problems in coordination with the multidisciplinary health care team.

  • Comprehensive chart prep in advance of patient office/nurse visits, including ordering of pertinent labs/tests per approved standing orders.

  • Provides liaison between front desk, providers, and health care team members to ensure timely and orderly flow throughout the clinic.

  • Anticipates provider & patient needs prior to and during visits.

  • Triages same day and emergency patients (by either phone or “walk-in”) and refers to the appropriate level of care (e.g. ED, same day appointment, future appointment, home care).

  • Triages and develops plans for multiple patient concerns and questions over the telephone.

  • Arranges urgent or medically complex referrals.

  • Consults and communicates with outside providers, including nursing homes, pharmacies and specialty providers to meet patient care goals.

  • Completes tasks associated with chronic disease management, and symptom presentation, in the rooming process:

  • Blood glucose test for patients with diabetes;

  • Peak flow, pulse oximetry for asthma exacerbation, COPD, pre- and post-nebulizer treatment;

  • Urine dip for symptoms of urinary tract infection/pregnancy;

  • Rapid strep test for sore throat.

  • Review lab results for urgent abnormal results.

  • Performs patient follow-up, including notifying patients of laboratory results per provider direction, schedule patients for follow-up or RN visits.

  • Communicates significant findings/changes in patient condition to the provider in a timely basis.

  • Documents accurately, objectively, timely and completely and includes a plan of care.

  • Performs venipuncture as necessary and other basic in-house lab tests per standing order(s) as approved by the provider

  • Obtains EKGs and various Point of Care testing as part of the assessment process.

  • Works within a multidisciplinary health care team to provide care and meets clinical performance measure goals/performance metrics for quality care, resource utilization, e.g. emergency room use and patient satisfaction.

  • Implements the medical and nursing plan of care using the nursing assessment of the patient’s readiness to learn, educational needs and preferences and agreed-upon self-management goals.

  • Educates patients in a wide variety of health care subjects such as nutrition and life style issues, sexually transmitted diseases, basic health care maintenance, chronic disease management and processes, medication action and side effects, self-administration of medications.

  • Prioritizes and coordinates patient care, connects patients to resources, monitor progress with health goals.

  • Maintain emergency equipment and supplies.

  • Maintains prescription sample closet inventory accurately with controls as directed.

  • Leads the Care Team Coordinators, including regularly assigning, instructing, and checking the work of those employees on an ongoing basis.

  • Attends staff, clinic, care team and in-service meetings.

  • In collaboration with clinical leadership develops and implements strategies for the care team to manage provider panels in achieving clinic performance measure goals/performance metrics.

  • Demonstrates awareness and actively strives to achieve quality performance measure goals/performance metrics. Actively participates in POD/care team initiatives.

  • Provides performance feedback to the Office Manager and Clinical Services Manager on Care Team Coordinators, LPNs and Medical Assistant(s). May participate in the performance evaluation process with Office Manager and Clinical Services Manager for members.

  • Remains knowledgeable of payer sources that may affect patient care and knowledgeable of assistance programs and community resources available to patients.

  • Demonstrates awareness of and access to community resources, including other services offered (Behavioral Health, Free Clinic, etc.)

  • Follows disease specific protocol management.

  • Works as a Care Team Coordinator to cover absences and work load.

  • Potential for other duties as role expands and as assigned.

  • Performs other duties and responsibilities as assigned.

Addendum for Care Team Nurse with RN Licensure

  • Performs independent RN visits for both acute and chronic conditions in collaboration with provider. May also assist the provider with office visits for case managed or complicated patients to take history, collect outside records needed, obtain vitals and lab specimens, provide health education, perform wound care, coordinate care, connect to resources, arrange follow up. Phone management of test results and plan.

  • Provides nursing care, including patient education, assessments, nursing intervention, medical case management and procedures.

  • Develops and implements plans on assessing needs of patients with complex medical and social problems in coordination with the multidisciplinary health care team.

  • Implements the medical and nursing plan of care using the nursing assessment of the patient’s readiness to learn, educational needs and preferences and agreed-upon self-management goals.

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