Patient Engagement Nurse – Pittsburg, Kansas


ABOUT THE POSITION

Patient Engagement Nurses at CHC/SEK are motivated and passionate about improving health outcomes for patients with chronic disease. They strive to understand, motivate, and help our patients achieve their goals in health and wellness by building rapport, eliminating barriers, collaborating with patients to set goals, and working within a multidisciplinary care team. Chronic Care Nurses assist patients with medical and other chronic care management needs through innovative methods in clinical and nontraditional settings such as a patient’s home or community. Chronic Care Nurses must be flexible, knowledgeable about disease processes, community resources and CHC/SEK care systems, and able to address barriers to improved health outcomes. This position is part of the Patient Engagement team, which focuses on clinical and non-clinical care management and coordination, benefits enrollment, social service navigation, community outreach, home visits, and administering patient-centered education and programming. The team utilizes evidence-based practices to outreach to defined patient populations and receives referrals from both the clinical staff and community partners to advance key community health indicators.

RESPONSIBILITIES

  • Engage at-risk, underserved populations, and work to decrease the impact of exacerbations on health status and accelerate recovery through targeted care management.
  • Facilitate comprehensive transitional care services and identify opportunities to reduce patient use of emergency services and avoid unnecessary hospital stays.
  • Provide clinical judgement for chronic care management and consult with providers and other members of a patient’s care team.
  • Provide chronic disease education so patients understand more about their chronic conditions, related medications, and treatment plans.
  • Provide coordination and management of care within an interdisciplinary team that further supports retention, wellness, and overall health.
  • Implement care management services on an ongoing basis to promote continuity throughout a patient’s care, which may mean working with the same patient for a few months to a year or more.
  • Create and periodically update patient specific care plans that include clear goals, priorities, and realistic actions to achieve their goals. In addition to goal setting, care plans include performing medication reconciliations, obtaining complete medical history, health risk assessments, and preventive and behavioral health screenings.
  • Support care plan progress by scheduling annual exams and follow-up appointments, attending appointments as needed, scheduling transportation, accessing prescriptions, or other preventive care services as needed.
  • Use skills like motivational interviewing and shared-decision making to engage patients in the development of health and social support goals, coaching patients in the effective management of their health conditions and utilizing self-care techniques.
  • Assess the patients’ unmet health and social needs to connect with community and organizational resources, including clear guidance about why and how to access these resources.
  • Work from a strength-based perspective to emphasize a patients internal and external resources.
  • Build trusting relationships and follow up with patients about their health via phone calls, home visits, and visits to other settings as needed, serving as a clinical liaison between the community and the health care system.
  • Practice cultural humility, avoid making assumptions about the knowledge, behaviors, or values of patients, working to transfer power to patient through self-management skills.
  • Utilize technology and telehealth capabilities to better connect the patient to care.
  • Work collaboratively, respectfully, and effectively within the Health Advancement team, a patient’s support system and clinical care team.
  • Build and maintain positive, supportive working relationships with clients, patients, providers, community organizations, and others.
  • Contribute to and utilize data to achieve program goals, improve health outcomes, and advance community health indicators.
  • Work to address health disparities for vulnerable populations by looking to innovative workflows and processes, or contributing to operational changes.
  • Maintain a library of health promotion and patient education materials and community resources.
  • Perform other duties as assigned.

QUALIFICATIONS

  • LPN or RN licensed to practice in Kansas required.
  • Two years nursing experience in an outpatient setting, preferred.
  • Previous care management and/or behavioral health experience preferred.