Community Clinic Inc.
Location
Silver Spring, MD | United States
Job description
CCI Health Services’ mission is to deliver high quality, accessible care to our community members, leading the way to a more equitable health care system for everyone.
POSITION SUMMARY
The Lead Registered Nurse - Care Coordination (Lead RNCC), under the direction of the Director of Nursing and the clinical care team, serves as an integral member of the nursing and CCI health center leadership team. The Lead RNCC participates in administrative and organizational leadership activities, develops care models, frameworks, training and documentation standards for care coordination and management at CCI. They support the CCI team in providing high quality, direct, evidence-based patient care and care managing high risk patients with chronic illnesses, to promote health education, condition management and self-advocacy to ensure improved patient and financial outcomes.
KEY FUNCTIONS AND RESPONSIBILITIES
Leads the care coordination program to support comprehensive care management, health promotion, comprehensive transitions of care, and referral to social support services.
Supervises care coordination nursing team – including assigning duties, coaching, hiring, training and corrective action.
Monitors population health outcomes against standards and engages in quality assurance and quality improvement activities to suggest improvements related to care coordination and management.
Builds and continually assesses care plans, needs assessments including readiness for change, discharge procedures and monthly disease assessment in the electronic medical record.
Supports preventing disease exacerbation and improving outcomes, increasing patient engagement in self-care, decreasing risk status, and minimizing hospital and ED utilization amongst CCI’s patient population.
Maintains a panel of episodic care coordination and chronic care management patients utilizing behavioral strategies to develop patient-centered care plans, setting patient-centered goals, and continually assessing patient’s self-advocacy, self-management, and barriers.
Develops systems and leads case review and clinical coordination with the clinical care team.
Develops, enforces, and maintains policies, procedures, workflows, and clinical guidelines.
Attends and participates in meetings, committees, health fairs, events and training as assigned.
Consistently seeks avenues for education and trains the care coordination team to maintain compliance with evidence-based practice and advancements in nursing care coordination and management.
Maintains the patient’s electronic medical record within expected timeframes, following CCI standards for charting.
Provides quality customer service and communicates in a HIPAA compliant, culturally sensitive, and trauma-informed manner.
Works within the policies and procedures of CCI Health Services Inc.
Two days of clinical care per week required for this position and may require travel between CCI sites to provide coverage as needed.
Performs other duties responsibilities as assigned by the Director of Nursing or designee.
MINIMUM QUALIFICATIONS:
Active RN license issued by the State of Maryland Board of Nursing or any state under the Nurse License Compact.
Minimum of three (3) years of nursing experience, with care management/coordination experience and progressive leadership experience a plus.
Current BLS/CPR certification required.
Excellent written, verbal, telephone, and interpersonal communication skills with experience documenting in an Electronic Medical Record (EMR). Specific knowledge of eClinicalWorks (eCW) is a plus.
Prior experience in a lead or supervisory capacity a plus.
Written and oral fluency in English.
WHY WORK AT CCI?
We are an approved FQHC for the NHSC loan repayment program (with an HRSA score of 19).** NHSC Student Loan Repayment Program recognizes CCI Health Services as an approved FQHC participant. Learn more: National Health Service Corps Students to Service Loan Repayment Program Application and Program Guidance (hrsa.gov)
** CCI Health Services is an Equal Opportunity Employer **Founded in 1972, CCI Health Services is a diverse and inclusive workplace grounded in community. Located in the Washington, DC Metro Area, each year CCI cares for more than 60,000 individuals in Montgomery and Prince George’s Counties. As a non-profit, CCI is committed to improving health equity through the provision of affordable primary care for all, across all stages of life. Visit ccicares.org for more information.
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