Responsibilities:
As member of physician office practice provides consultation and works collaboratively with providers on patient cases. Reviews or completes initial patient assessment including comprehensive medical psychosocial and functional assessment of patient which may require performing same in patient home setting as necessary. Ensures screening tests are current.
Provides detailed education about patient�s specific chronic illness including pathology signs and symptoms complications and medications used in treatment.
Utilizes multidisciplinary team approach to address opportunities to plan and coordinate care.
Coordinates interactions with ancillary personnel.
Establishes care management plans interventions treatment goals (including self-management goals) and contact schedules:
Promotes compliance with chronic care plan
Coordinates care and communicates with multiple providers both within and external to the practice
Reviews test results and tracks outcomes; refer test results exceeding acceptable ranges to practitioners
Reviews patient compliance issues
Evaluates effectiveness of plan in meeting established care goals
Revises plan as needed to reflect changing needs issues and goals
Arranges group visits
Performs a variety of professional nursing and technical duties and supervises medical assistants performing similar functions as applicable:
Performs/records telephone and in-office triage according to guidelines
Prepares patients for examination. Obtains and records temperature blood pressure height/weight head circumference (newborn)
Performs diagnostic testing including EKG Urine dipstick and centrifuge prep for micro slide exam Vision Screening Strep Tuberculin Tympanometry and Audiometry
Assists practitioners with examinations procedures and minor surgeries: applies principles of sterile technique prepares exam areas equipment and supplies and performs clean-up of patient area per OSHA standards.
Provides patient education: assesses readiness to learn and barriers to learning identifies appropriate resources and techniques prioritizes learning needs adjusts level of presentation to audience provides environment conductive to learning establishes method for evaluation of learning and evaluates patient�s/families� response to teaching
Administers medications considering age specific needs: allergy injections with monitoring Intramuscular Subcutaneous Intradermal and Oral
Maintains medical records in compliance with audit standards: obtains patient identification data reason for visit pertinent medical history and written consent for treatment. Dates and signs entries records known diagnosis drug allergies and medications
Conveys prescription renewal information to pharmacies per practitioner�s direction
Manages health information such as testing reports correspondence and other documents: appropriately uses electronic medical record relays pertinent information to providers for action and shares files and messages with providers and support staff
Schedules patient appointments: office visits per provider�s guidelines outpatient diagnostic services consultations with other providers and obtains insurance authorizations as indicated
Performs medical office leadership functions:
Organizes coordinates and leads work of office staff to ensure organizational objectives are accomplished according to established work standards
Responds to day-to-day needs of patients providers and support staff
Collaborates with Ambulatory Clinical Manager and other Nursing Care Managers to develop master staffing schedules. Jointly coordinates daily staffing and assignment adjustments as needed adjusting scheduled hours to accommodate patient volume
Coordinates work flow in offices
Monitors and accurately reports time worked by staff
Participates in interviewing/selection of new staff
Instructs staff in proper work methods techniques use and care of equipment safe working practices policies and procedures. Coordinates orientation program for new staff
Assists with development and coordination of staff competency assessments. Conducts and documents introductory and annual competency assessments of staff
Provides basic reinforcement or coaching to staff as needed. Reports areas of concern to Ambulatory Clinical Manager
Provides Ambulatory Clinical Manager with routine performance feedback on staff. Provides input for and participates in staff performance evaluations.
Recommends staff learning needs
Serves as role model and resource to staff. Participates in employee engagement efforts.
Maintains adequate inventory of office and clinical supplies.
Supports administrative functions relative to compliance and organizational standards: preparations for Licensure Regulatory and Accreditation Preparations for Risk Management Safety Security and Emergency Preparedness Compliance with Incident and Medical Event Reporting Compliance with policies and procedures and Coordinates CLIA controls maintenance for laboratories
Maximizes usage of electronic medical record/chronic disease registry reporting to effectively prioritize patient follow up activities.
Initiates and maintains effective relationships within community as required by patient population. Demonstrates flexibility and creativity in recommending resources to meet patient/family needs such as identifying and utilizing appropriate cultural and community resources to support needs of diverse patient population.
Functions as Patient-Centered Medical Home liaison to hospitals long-term care institutions specialists and home health representatives to coordinate administrative and clinical issues related to patient care.
Ensures open communication regarding patient status with physicians and office staff.
Participates in quality improvement and evaluation processes related to Care Management.
Reviews pertinent literature about case types managed and best practices in patient-centered medical home to share with team members.