Job Information
Kansas Employer Patient Engagement Nurse (Pittsburg South) in Pittsburg, Kansas
This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/12848251 GENERAL DESCRIPTION
The Patient Engagement Nurse 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. Patient Engagement Nurses assist patients with medical and other chronic care management needs through innovative methods in clinical and nontraditional settings such as a patients home or community. Patient Engagement 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.
Requirements
ESSENTIAL DUTIES
Engage at-risk, underserved populations, and work to decrease the impact of exacerbations on health status and accelerate recovery through targeted care management.
Provide clinical judgement for care management and consult with providers and other members of a patients care team.
Provide chronic disease education so patients understand more about their chronic conditions, related medications, and treatment plans.
Implement care management services on an ongoing basis to promote continuity throughout a patients 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.
Contribute to and utilize data to achieve program goals, improve health outcomes, and advance community health indicators.
Perform other duties as assigned.