The Lead Registered Nurse Care Coordinator, under the direction of the Registered Nurse Manager, has primary responsibilities for monitoring and ensuring implementation procedures at the health center in addition to care management activities for a site-specific patient panel at CCI Health Services. The Lead Registered Nurse Care Coordinator helps to maintain a culture that fosters patient empowerment, teamwork, and the delivery of high-quality, evidence-based care. The Lead Registered Nurse Care Coordinator will work with the Health Center Medical Director and Health Center Manager as part of the Triad Team to develop this position to best serve the needs of the patient panel. This includes the development and maintenance of policies, procedures, formal agreements for referrals, partnerships with agencies that issue grants, the state and county health departments, program evaluation, and quality improvement. The roles of the Lead Registered Nurse Care Coordinator include but are not limited to leading the daily workflow and serving as an integral member of the clinical primary care team, identifying high-acuity patients to monitor within the Care Management Program fostering the Patient-Centered Medical Home, and leadership and administrative tasks. Through identifying goals and needs, the Lead Registered Nurse Care Coordinator will formulate a plan to coordinate care, services, and resources for the designated patient panel to facilitate improved health outcomes.
As a member of the health center’s integrated care team, the Lead RNCC fulfills the following KEY FUNCTIONS AND RESPONSIBILITIES for the provision of:
Serving as lead for the nursing department at their site as part of the Triad team
Promotes and fosters an atmosphere of teamwork and excellence among staff.
Leads by example to provide Center-wide high-quality care that is patient-centered and meets CCI Health Services’ established standards.
Facilitates huddles every morning according to the designated template.
Participates in Triad Meetings with Health Center Manager and Health Center Medical Director; identifies items or issues requiring further resolution. Attends other site-related meetings, nurse meetings, and leadership meetings as requested.
Regularly conducts site-level Quality Improvement staff meetings to discuss issues and corrective measures to meet goals.
Participates in Performance Improvement activities as needed. Assists with analysis of quality improvement data for the primary care team and helps identify ways to improve care using Relevant tools. Assists with collecting needed data and generates reports as assigned.
Prepares and leads team huddles, identifying patients presenting with complex medical problems (who may need additional assistance such as care management or other), assisting the provider-MA teams in the provision of quality comprehensive patient care, and promoting an interdisciplinary approach to care.
Helps develop policies and procedures.
Assists with new employee training and ongoing training for other team members including Medical Assistants.
Consistently seeks avenues for self-education in order to broaden knowledge base with regards to health risks, diseases, new clinical procedures, treatments, new drugs, and best practices.
Attends health fairs and other health center events as requested.
Actively managing assigned Care Management panel of high acuity, chronically ill, and medically complex patients.
Assists in developing care management workflow for CCI Health Services’ staff, including recommended guidelines for referral to care management, and communication practices with the primary care team. Assists Clinical Directors with systems, processes, outcomes of clinical care teams, and programs designed to address the clinical, psychosocial, and financial needs of patients and families. Assists in developing methods for monitoring patient outcomes for those enrolled in care management. Development of pre-visit planning workflow, to ensure the efficiency of care, prior to visit whenever possible.
Continues reassessment of client’s status and satisfaction with services rendered in order to evaluate progress toward goal achievement; determine the need for further services and make an adjustment to the care plan. Discontinues services when the client no longer needs or desires services, or becomes ineligible for services, and documents discharge plan in the client’s record.
Delivers care in accordance with CCI guidelines and scope of training as a Registered Nurse to clients/patients from infancy to geriatrics.
Oversees Licensed Practical Nurses in accordance with CCI guidelines and scope of training as an LPN to clients/patients from infancy to geriatrics.
Provides quality customer service at all times; communicates effectively with patients in a manner that protects their confidentiality, and is sensitive to their culture, and physical, emotional, and spiritual needs.
Anticipates the needs of the patient population, completes necessary documentation and pre-visit planning, addresses areas of concern, and requests for patient’s pertinent records prior to visit.
Documents accurately and comprehensively, based on the standards of practice and current organization policies.
Provides direct care to patients, including physical assessment of presenting signs and symptoms, plans care in collaboration with a provider, executes treatment plan as directed by the provider, and evaluates results while utilizing age-specific and universal precaution guidelines.
Triages patients on the phone and as walk-in patients; consults with a provider for an appropriate plan of care as needed.
Provides point-of-care testing, such as urinalysis or pregnancy tests, etc., to aid in diagnosis and treatment; other services include, but are not limited to vaccination of clients, delivery of treatment to severe asthmatic patients, administration of medications including injections as ordered by the provider, care of patients who have or, are exposed to communicable diseases such as tuberculosis, HIV or AIDS.
Promptly attends to phone calls and completes telephone encounters, providing appropriate medical advice to patients complaining of signs and symptoms of illness. Uses approved and current medical advice for all patient populations, including but not limited to pediatric, obstetric/gynecologic, and geriatric.
Counsel patients on the use, benefits, risks, and potential side and adverse effects of any medications prescribed.
Assists with tracking and reviewing lab results; executes provider’s orders in a timely manner as directed, after reviewing of results by the medical provider.
Upon order from a medical provider, implements standing prescriptive orders for patients.
Review after-visit summaries with patients whenever appropriate. Provides follow-up contact with the patient as indicated to ensure compliance with recommendations – medications, lab/x-ray, specialist visits, Primary Care Provider (PCP) visits, dieticians, Certified Diabetic Educator, other consults, etc.
Acts as liaison to hospitals, MCOs, and other community-based services to coordinate care for CCI. patients and to develop and strengthen collaborative relationships at the organizational level.
CCI Health Services is a 49-year-old Federally Qualified Health Center is a diverse and inclusive workplace that serves 60,000 medical patients and Women Infant’s & Children (WIC) participants in Montgomery and Prince George’s Counties. As a 501(c)3 non-profit, CCI is committed to providing high-quality, affordable primary healthcare to every patient across all life stages. Visit www.cciweb.org for more information.