Job Description
Primary Care Health Home Nurse Exempt position accountable to the RN Population Health Programs Director. Responsible for development and care management of Primary Care Health Home patients. Performs all duties required of this programs within scope of a state of Missouri Licensed Registered Nurse (RN) and provides assistance to and direct supervision of team members functioning in roles of care management and in support of PCHH and related programs. Essential Job Responsibilities Direct relationships with patients and coordination with primary care team, specialty care teams, and inpatient facilities. Develop care plans, monitor medication adherence and reconciliation, identify and address high utilizers. Must know and adhere to the Mission, Vision and Values of Four Rivers Community Health Center. Utilize critical thinking skills to interpret and act in accordance with Four Rivers Community Health Center Mission, Vision, and Values in a variety of complex situations. Demonstrates understanding of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and comply with patient information safeguard guidelines to protect patient information. Demonstrate expert communication skills with patients, Four Rivers Community Health Center administrative and multidisciplinary team members, and community partners. Use evidence-based guidelines, literature, program assistance letters (PALs), official manuals and regulations, and appropriate nursing assessments to assist in the coordination of care of individual patients and management of population health to include but not limited to social determinants of health (SDOH), chronic disease management, ER utilization and hospital admissions. Be proficient at utilizing the EHR, DRVS, Cyber Access, eMOMED, Health Information Exchange (HIE) connected portals, and other applicable data sources to obtain patient information