Clinic Nurse

Position

The Care Management Nurse supports primary care providers in delivering comprehensive, patient centered services. The position focuses on care management for patients with chronic and complex health needs and functions as a provider extender to increase access, improve quality, and support continuity of care. The nurse works as a core member of the interdisciplinary care team and contributes to clinic quality and performance measures.

• Conducts care management activities for assigned patient panels, including review of registries, identification of care gaps, and outreach to patients who are overdue for visits, tests, or preventive services.
• Functions as a provider extender by assisting with rooming, vital signs, medication and allergy review, and visit preparation in accordance with license, standing orders, and clinic protocols.
• Provides patient and family education on chronic conditions such as diabetes, hypertension, asthma, and depression, and reinforces provider care plans and self management goals.
• Coordinates care with the care coordinator for referrals, social needs, and benefits. Ensures that care management activities and care coordination activities are aligned.
• Supports transitions of care from hospitals and emergency departments, including medication reconciliation, follow up appointment scheduling, and monitoring of post discharge needs.
• Documents all care management and clinical activities in the electronic health record in a timely, accurate, and complete manner, using approved templates and workflows.
• Participates in daily huddles, case conferences, and quality improvement activities to support achievement of UDS, HRSA, and other regulatory and funder quality measures.
• Adheres to policies and procedures for infection control, medication management, safety, privacy, and confidentiality, and maintains compliance with applicable federal and state regulations.
• Works with the medical assistant to plan and manage daily patient flow. Helps coordinate tests, vaccines, procedures, and follow up needs.
• Follows all policies and procedures related to infection control, medication management, safety, privacy, and confidentiality. Maintains compliance with applicable federal and state regulations.
• The position may also support vaccine clinics, health fairs, community outreach events, nurse visits, and telephone triage as assigned.

• Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice.
• Experience in primary care, community health, or clinic setting is preferred.
• Experience working with diverse and underserved communities is preferred.
• Knowledge of primary care nursing, care management principles, chronic disease management, and preventive care.
• Skill in patient assessment, patient education, and coordination of care within an interdisciplinary team.
• Ability to use electronic health records and standard office software.
• Strong written and verbal communication skills and attention to detail.
• Demonstrated commitment to health equity, cultural humility, and trauma informed care
• Spanish or Vietnamese bilingual skills preferred but not required.

• Work is performed in an outpatient clinical environment.
• Requires regular standing, walking, bending, and light lifting consistent with clinical duties.
• Requires use of personal protective equipment as defined by organizational policy.