CCAP Mission Statement - To empower all people and communities, challenged by poverty as well as social and cultural barriers, through advocacy, education, and access to high quality health and human services.

SCOPE OF ASSESSMENT AND PATIENT MANAGEMENT:

The Nurse Care Manager will have the opportunity to work on a multidisciplinary healthcare team in a community health clinic care setting. The Nurse Care Manager will be part of a program charged with working within the patient care medical home and administering health care in a new and innovative way. The Nurse Care Manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education and self-management support to patients with chronic health conditions, such as, coronary artery disease and depression.

 WORK SCHEDULE DEMANDS

• The position is full time.
• Occasional unscheduled overtime.
• May be required to work in any Family Health Services’ locations at the discretion of the Director of Quality Improvement and Compliance/ any CCAP location.

REQUIRED QUALIFICATIONS

• Licensed Registered Nurse from an accredited school.
• Three (3) to five (5) years’ experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
• Current BLS certification
• Experience working with patients regarding their care coordination and disease management / education is preferred. Perform quality work within deadlines with or without direct supervision.
• Share best practices among all teams, serve as a medical home advocate, mentor and lead by example to support a positive work environment, and encourage other staff to do the same.
• Represent the practice in a positive manner to all patients and all applicable external clients.

KEY RESPONSIBILITIES

• Works under the direct supervision of the Nursing Director.  
• Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed.
• Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
• Assure that preventive screening tests are up to date.
• Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules.
• Promote compliance with chronic care plan.
• Coordinate care and communicate with multiple providers, both within and external to the practice
• Review test results and tracks outcomes.
• Review patient compliance issues.
• Work one-on-one with patients.
• Arrange group visits.
• Leverage EMR / chronic disease registry reporting to prioritize patient follow-up.
• Identify and utilize cultural and community resources.
• Develop quarterly reports on service volume, distribution of patients by plan, and types of services provided.
• Ensure open and effective communication, regarding patient status, with physicians and office staff.
• Act as liaison to hospital, long-term care and specialists.
• Attend required training and collaboration sessions [i.e., learning sessions, outcomes congress, care management collaboration meetings, and practice team meetings] as scheduled.
• Train staff on motivational interviewing
• Interact and coordinate with insurance companies’ and other external agencies’ Case and Disease Management staff, when applicable in caring for the patients within the Patient Centered Medical Home.

COMMUNICATION SKILLS:

• Interpreting technical medical terminology daily.
• Use all available methods of communicating with patients, such as
• Interpreters, individual counseling, group discussions, written materials, and visual aids.
• Communicating and identifying cultural, social and economic character of
• the patient population served.
• Ability to communicate with staff and providers tactfully and effectively.

CONFIDENTIALITY OF INFORMATION:

• Full access to client's medical record and some access to financial/ statistical material.
• Maintains client confidentiality at all levels of interaction in accordance with State and Federal
• Laws and CCAP policies and procedures in the form of presentations, flyers, group work, etc.

PHYSICAL EFFORT / ENVIRONMENT:

The physical demands and work environment 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. 

While performing the duties of this job, the employee is regularly required to sit and to talk to hear. The employee frequently is required to use hands, fingers, handle or feel objects, tools or controls and reach with hands and arms. The employee is occasionally required to stand and walk. The employee must occasionally lift and / or move up to 20 lbs. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Potential exposure to blood borne pathogens, respiratory diseases and other infectious diseases, and other biohazardous material requiring universal standard precautions.

Our Benefits

Our comprehensive benefits package includes 403(b), health insurance, vision and dental insurance, flexible spending accounts, health reimbursement accounts, tuition reimbursement up to $1,000 annually, an Employee Assistance Program, generous vacation, sick and personal days, and up to 13 paid holidays for all eligible employees. Some benefits are included for part-time employees.

CCAP strives to cultivate and sustain a workforce devoted to providing compassionate and respectful care to all patients and clients. We are an Equal Opportunity Employer, committed to providing equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, and gender identity), national origin, age, disability, genetic information, marital status, familial status, military status, or any other characteristic protected by federal, state, or local law. This applies to all terms and conditions of employment, including but not limited to recruiting, hiring, placement, promotions, terminations, layoff, recall, transfer, leaves of absence, compensation, and training.