Location: Baltimore, MD, USA
Highlights (Bonus, shift, relocation, info for job):
Monday through Friday, 8-5 with hour lunch, no weekends, no on-call, with paid holiday time off
This role works with a dedicated Primary Care Provider and supports primary care activities for the PCP panel, including patient education, orders, referrals, and medication management, and addressing gaps in care. The Team Nurse works directly with members to achieve their care plan goals through patient education, care coordination, and building relationship.
Duties and Responsibilities
- Act as the practice-based nurse, supporting on-site providers in facilitating high quality primary care that promotes appropriate healthcare utilization.
- Facilitate Patient Centered Medical Home (PCMH) functions through management of diagnostic order tracking, medication refills, review of the medical record, and fielding messages from members and the integrated care team.
- Lead panel management for members attributed to the assigned primary care provider through activities including, but not limited to, following disease care pathways, entering standing orders for preventive care, and leveraging available reports to close care gaps.
- Monitor access to the primary care provider. Ensure members have scheduled follow-up.
- Coordinate services to complete primary care provider action plan tasks.
- Meet with members in the medical center as an extension of the primary care provider to address member needs, including medication reconciliation and teaching and coaching for effective disease management.
- Engage members telephonically between primary care visits to support PCMH activities, panel management, and action plan completion.
- Prepare for and participate in daily huddle with the integrated care team.
- Act as a bridge between the primary care provider and the greater integrated care team. Coordinate internal referrals between team members.
- Coordinate with the Immediate Care Area to provide in person and telephonic triage. Perform nursing interventions including wound care, IV (intravenous) therapy, and phlebotomy as needed.
- Provide coverage support for fellow care team members as needed, including point of care testing, medication administration, and office flow.
- Leverage strong time management skills to prioritize and balance member care responsibilities with provider panel management and role-specific tasks.
- Active, unrestricted license as a Registered Nurse in the state of practice required. Compact RN license preferred, or willingness to obtain.
- 3+ years of experience providing clinical services to Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions.
- Active CPR certification.
- Experience working for a community-based organization preferred.
- Proficiency in clinical nursing skills such as wound assessment and care, venipuncture and phlebotomy, and assessment and management of common chronic conditions such as diabetes, hypertension, CHF, and COPD.
- Excellent interpersonal communication, problem solving, and organizational skills.
- Independent self-starter and critical thinker interested in population health, healthcare utilization management, and the ongoing development of our care model.
- Proficiency with Microsoft Office applications.
This job operates in a professional office environment. This role routinely uses general office equipment. Often wear a special uniform, such as a lab coat or surgical scrubs, protective or safety attire, such as gloves and masks. Exposed to the diseases and infections of patients daily. May share workspace with other technicians and staff.
- Ability to communicate clearly and exchange accurate information constantly.
- Ability to remain stationary for long periods of time.
- Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
- Ability to occasionally move objects up to 20 lbs.
Why Work at AbsoluteCare?
At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer.
We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.
We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works.
Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT2.
AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.
EEO Employer Verbiage: AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.