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 26 outpatient health centers in El Paso, Teller, Lincoln, Adams, Arapahoe, Elbert, and Kit Carson counties. We deliver care with our strong “Hospitality” culture. Our organization has over 900 employees and serves 94,000 patients in the Pikes Peak & East Central region. Peak Vista is accredited by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC).

Job Description:

Summary: The Care Team Nurse functions as a liaison between the patient and members of the Care Team in a joint effort to optimize the patients’ health status and quality of life. 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.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Assess and triage for the appropriate level of care based on comprehensive risk assessment including diagnosis, clinical judgment, and outcome goals
• Assess patients readiness for change, physical and psychosocial needs
• Identify and link patients to available resources, social support systems, family support, etc.
• Assess 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, 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
• Triage and appropriately delegating follow up needs for patients in regards to labs and any outside testing
• Patient advocate
• Able to provide education as needed to include disease processes and medication regimen
• Works with the care teams to assure schedules reviewed, patients charts prepared for visit
• Understands the immunization schedule and is able support clinic staff and patients
• Employee demonstrates knowledge of and adherence to the Compliance Plan and conflict of interest requirements. The employee enhances the effectiveness, efficiency and productivity of the department by contributing to, and participating in, departmental performance improve goals.

Supervision Exercised: None

Suggested Competencies:

Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:
Graduate of an accredited Nursing Program required; BSN preferred.

Work Experience:
Two years' experience in case management and clinical nursing preferred.

Language Ability:
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Math Ability:
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Reasoning Ability:
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills:
To perform this job successfully, an individual should have knowledge of Word Processing software; Internet software and Database software. Word, Excel, Electronic Health Record.

Certificates and Licenses:
Current Colorado RN License, Current CPR (BCLS) certification

Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OSHA Risk Level/Work Environmental Hazards:
This position has been categorized as OSHA Level One. (See PVCHC's Exposure Control Plan for details). The noise level in the work environment is usually quiet.

Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must occasionally lift and/or move up to 50 pounds. While performing the duties of this Job, the employee is regularly required to stand and walk.

*Successful candidates will complete pre-employment screening; which includes, but is not limited to a Criminal Background check. Peak Vista Community Health Centers is a drug and alcohol free workplace an an Equal Opportunity Employer.