|Title:||Care Team Nurse|
|Locations:||3207 N. Academy, Ste. 3100|
|Category:||Nursing / Allied Health / Clinical Support|
Peak Vista Community Health Centers is a non-profit healthcare organization whose mission is to provide exceptional healthcare to people facing access barriers. We provide primary care services (medical, dental and behavioral healthcare) through 27 outpatient health centers in El Paso, Teller, Lincoln, Adams, Elbert and Kit Carson counties. We deliver care with our strong “Hospitality” culture. Our organization has over 850 employees and serves over 90,000 patients in the Pikes Peak and East Central Plains region. Peak Vista is accredited by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC).
Job Summary (Essential Functions)
As an integral member of the Care Team, the Care Team Nurse functions as a liaison between the patient and other members of the Care Team in a joint effort to optimize the patients’ health status and quality of life. The Care Team Nurse will work collaboratively with the patient and the Care Team to identify and develop an appropriate plan which will assist the patient to achieve their wellness goals. The Care Team Nurse will perform routine and emergent nursing functions pertinent to efficient, ambulatory patient care, while following the guidelines set forth by the Colorado Nurse Practice Act.
- Assessing and triaging for the appropriate level of care based on a comprehensive risk assessment including diagnosis, clinical judgment, and outcome goals.
- Assessing patients readiness for change
- Assessing patients physical and psychosocial needs
- Identifying and linking patients to available resources, social support systems, family support, etc.
- Assessing high risk and rising risk patients consistent with the current Policies & Procedures for Care Management
- Facilitates access to quality and cost effective care
- Collaborates with and maintains healthy working relationships with community partners
- Provides education to the patients, families and care-givers
- Encourages engagement and self-management of patients with regards to their own health
- Provides outreach to individuals as well as the community
- Provides in-reach to patients who are presently inactive in their healthcare
- Demonstrates an ability to utilize technology to include, but not be limited to, the Electronic Health Records, state registries, Health Information Exchange
- Maintains documentation of all interactions accurately and completely, implementing appropriate protocols for patients’ charts and billing practices
- Maintains healthy working relationship with team members as well as staff from all levels of the organization
- Supports the clinical training department and assures the Medical Assistants are competent in regards to clinical skills.
- Assists providers with inbox tasks to include medication refills (per standing order SOP) and completing pertinent paperwork for patients outside needs.
- Triaging and appropriately delegating follow up needs for patients in regards to labs and any outside testing.
- Functions as a patient advocate
- Able to provide education as needed to include disease processes and medication regimen
- Works with the care teams to assure schedules are being reviewed patients charts are prepared for visit.
- Understands the immunization schedule and is able support clinic staff and patients
Education: Graduate of an accredited Nursing Program required; BSN preferred
Work Experience: Two years’ experience in case management and clinical nursing preferred.
Cognitive Skills (Language, Math, Reasoning Ability): Excellent language, reasoning and thinking abilities.
Computer Skills: Word, Excel, Electronic Health Record
Other Skills: Knowledgeable of community resources, sensitivity to low income and diverse groups of people, ability to work with families from a strengths-based model and strong interpersonal skills. Self-motivated. Valid driver’s license and insured automobile required.
Certificates & Licenses: Current Colorado RN License. Current CPR (BCLS) certification
Able to support/lift at least 50 pounds. Long periods of standing, moving, occasional periods of sitting. Hearing within normal range for telephone use. Must be able to get from one clinic site to related locations.
*Successful candidates will complete pre-employment screening; which includes, but is not limited to a Criminal Background check. Peak Vista Community Health Centers is an Equal Opportunity Employer.