| Position Summary: |
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| Coordinate all systems/services required for an organized, multidisciplinary, patient centered care team approach, and assure quality, cost-effective care for the identified patient population. Manage the course of treatment of patients, coordinating care with physicians, nurses and other staff ensuring quality patient outcomes are achieved within established time frames and with efficient utilization of resources. Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances. Function as a contact person for patient, family, health care team members, community resources and employees as necessary. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups. |
| Accountability: |
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PCMH/PCSP - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
DATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate
ASSESSMENT - Assess the patient's clinical, psychosocial status and current treatment plans
NEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources
ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment
REPORTS AND RECORDS - Maintain computer-based tracking system and compile required reports and records
COLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities
GOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members
PLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
DISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team members
VARIANCES - Intervene when variances occur in patient individualized treatment plan
RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary
VARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategies
TREATMENT CONFERENCES - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management
EDUCATION - Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control
INFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team
CONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant others
MEETINGS - Participate in team meetings when indicated or as directed
CARE PLAN - Incorporate recommendations and/or services of interdisciplinary team members in the care plan
COMMUNICATION - Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfaction
DOCUMENTATION - Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely manner
ORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriate
QUALITY - Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentation
COMMITTEES - Attend meetings and represent department or Hospitals within Hospitals related committees or the community, as assigned by supervisor
PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
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| Certification Requirements: |
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RN MATRIX - Complete and maintain unit/clinic based required certifications and competencies as listed in the department expectations/and or the unit/clinic education matrix
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| Education Requirements: |
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Nursing program (nationally accredited) graduate
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| Experience Requirements: |
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1 year directly related experience
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| Licensure/Certification Requirements: |
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CPR Certification for Healthcare/BLS Providers or for Professional Rescuers or must obtain within 30 calendar days of date of position
Licensed Registered Nurse (RN) in State of New Mexico or as allowed by reciprocal agreement by State of New Mexico
CAP III - Clinical Advancement Program Level III requirements satisfied
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| Education Requirements - Preferred: |
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Bachelor's Degree of Science in Nursing
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| Experience Requirements - Preferred: |
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Bilingual English/Spanish
Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo
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| Physical Demands Requirements: |
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Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.
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| Testing Requirements: |
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Tuberculosis testing is completed upon hire and additionally as required
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| Working Conditions Requirements: |
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Minor Hazard - physical risks, dirt, dust, fumes, noise
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