The Community Health RN is responsible for a team based nursing approach to managing patient needs. This RN will provide care coordination, advocacy, coaching and education for patients that are at risk for hospital admissions or ER visits. This nurse will also assess, manage and support patients, provide appropriate documentation and work collaboratively with the entire health care team. Direct patient care will give the RNs the opportunity to work to their full scope of patient care. Our goal as an organization is to have a team of RNs at each location working together to give our patients the best quality care for both chronic conditions and preventative measures, as well as improve quality measures for Oak Orchard Health

Job Responsibilities:

• Identify patients with high risk for adverse health outcomes, establish relationships with these patients to enable effective intervention and support. Create goals with patients and develop plan of care.
• Identify barriers of care to high risk patients, implement care plans with patients to provide self-management and support interventions. Optimize patient access to needed services through insurance and other benefits.
• Facilitate effective transition of care through the provision of comprehensive follow up to in-patient and skilled nursing admission when discharged home. Provide patient education in regard to discharge instructions and medication questions.
• Promote health maintenance in high risk population patient panel, and participate as a member of the Care Team. Work with outside agencies and providers to share patient information for best health outcomes.
• Assess incoming phone calls and walk-in patients needing triage.
• Assess and provide follow up for patient ED and UC visits.
• Assist in population health efforts focusing on preventative care and chronic condition management.
• Monitor patients on chronic anticoagulation therapy.
• Work in RN capacity to facilitate community outreach efforts such as vaccine clinics and direct patient care in the clinical setting.
• Provide culturally competent interventions based on patient assessment and identified cultural needs.
• Perform other duties as assigned.

Supervisory Responsibility:

• Delegate tasks to LPNs as appropriate when operating under non-patient specific standing orders

Skills / Qualifications:

• Excellent communication skills and ability to form collaborative partnerships across all service settings
• Working knowledge of the provision of health care in a variety of settings
• Knowledge of community resources preferable
• Ability to engage and build relationships with patients
• Ability to prioritize workload and assess the need for collaboration with the health care team
• Basic computer literacy skills, with competence in Microsoft Office products such as Work, Excel, Outlook and PowerPoint, and experience working in an electronic health record (EHR)
• Ability to assimilate new information and technologies into daily work
• Bilingual desired but not required
• Flexibility in schedule – some evenings and weekends may be required
• Graduate of an approved school of nursing with RN license to practice in NYS. Must maintain a current and valid registration certificate
• 2-3 years’ experience in Primary Care, inpatient or outpatient Internal Medicine/Family Medicine, Public Health, Case Management, or related field
• Current certification in Basic Life Support for Healthcare Providers or equivalent