Registered Nurse - Care Coordination

Greater Gardner
Gardner | GARDNER
175 Connors Street
Gardner, MA 01440, USA

• Pay or shift range: $33.50 USD to $41.59 USD
• The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.

$3,000 sign-on Bonus!

JOIN THE CHC FAMILY!

Community Health Connections (CHC) is a multi-site, non-profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, and substance use disorder treatment, and specialty services including optometry eye care, optical shop, acupuncture, nutrition consultations and podiatry. CHC is mission-driven, providing compassionate, quality health care regardless of income or health insurance status.

CHC has five sites within Fitchburg, Gardner and Leominster with decades of experience as a Federally Qualified Health Center (FQHC), serving 36 communities in North Central Massachusetts.

The Care Coordinator performs an integral role in the team-based approach to care, developing collaborative relationships with providers, patients and their significant others and other members of the care team. He/she ensures that high risk patients receive care that is consistent with national, state and health center standards and policies. The Care Coordinator supports patients and families in self-management, through evidenced-based approaches as appropriate, engages in health center projects aimed at specific patient population needs, and utilizes effective and appropriate communication strategies for issues such as health literacy and cultural norms when working with patients.

The RN Care Coordinator partners with Care Coordination Specialists and interpreters to ensure that patients are able to access culturally and linguistically appropriate services in a timely and cost effective manner. He/she participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.

• Completes an initial assessment actively involving the patient to determine care coordination needs.
• Utilizing motivational interviewing techniques, creates and updates care plans which address identified needs and emphasizing patient specific goals and self-management as they relate to desired medical outcomes. Partners with patient to encourage active participation in identifying patient’s own goals.
• Utilizes a collaborative approach with the PCP and other team members in creating the comprehensive action plan to help ensure that the patient receives a consistent message from all team members.
• Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s/families' level of independence in navigating the healthcare system at all levels of the continuum.
• Plans, coordinates, monitors and evaluates progress toward meeting goals in the plan of care.
• Serves as a liaison and patient advocate between the providers, health center, and community resources to facilitate access to services and improve the quality of the services delivered.
• Educates patient on and/or assist with establishing advanced directives.
• Integrates the patient/family members into care coordination and care management planning and communications, assuring the patient/family are informed and supported in decision-making.
• Provides ongoing verbal and written communication of patient’s needs, plan of care, progress and changes in status with the PCP, team and the patient/family through comprehensive physical, mental and psychosocial assessments.
• Executes medical orders for specific drugs, treatments, and other diagnostic or therapeutic procedures.
• Administers and records medication administration consistent with his/her knowledge of pharmacology in accordance with health center policy.
• Administers routine vaccines when not administered as part of office visits. Knowledgeable of current and catch‑up…