Registered Nurse

Join to apply for the Registered Nurse role at Community Clinic of Maui, Inc.

The Registered Nurse (RN) provides patient centered care which includes care coordination and health education to patients and their families utilizing the nursing process of assessment, planning, intervention, and evaluation. The RN will work in a clinical triad with the Medical Assistant (MA) and Medical Provider (MD/DO/NP/PA). This position also works closely with an interdisciplinary team including the medical care teams, Integrated Health team, Dental staff, Member Services and outside referral entities to ensure patient centered care.

The RN also plays an essential part in the clinic attaining the goals that administration has set forth for reaching Patient Centered Medical Home recognition, UDS standards and third‑party incentive programs. The RN will do this in a team‑based care model by functioning in the team as the primary care facilitator.

• Team‐Based Work Environment
• 90 Day Introductory Period
• Awesome benefits:
  Medical, Dental, Vision, life insurance, short & long‑term disability, and 403(b) Retirement Plan with a company match, FSA, and other voluntary benefits
• Generous Vacation, Holiday and Sick Benefits — effective 1st of the month following date of hire

• Follows the pre‑visit planning policy and procedure as established by the organization.
• Coordinates pre‑visit planning with Medical Assistant and Medical Provider on assigned team.
• Prepares for, attends and participates in team meetings and huddles.
• Works with Medical Assistant to contact all new patients presenting with Chronic Disease indicators, 5 to 7 days prior to their first visit in order to complete a Pre‑Visit assessment that includes medications, past medical history, medication list and problems. Completes screenings for depression, smoking, drugs, safety, etc. per current practice guidelines.
• Identifies High Needs Patients, described below, with Medical Provider and works with Medical Assistant to contact all identified High Needs Patients, 5 to 7 days prior to next visit to determine if care plan objectives from previous visit have been completed, if there has been interim care outside the organization and if the patient has any concerns that the team can prepare for.

• Confers with Medical Provider on team and participate in data gathering, setting patient expectations, patient education and care coordination of High Needs patients, as requested by the medical provider. These will consist of:
• Transfer of Care (TOC) Patients:
  • New Patients
  • Hospital/ER Follow ups
• Patients with poor control of chronic medical conditions
• Patients with anticipated barriers to data gathering of patient history and care needs:
  • Language barriers
  • Learning or cognitive disabilities
  • Mental Health or Behavioral barriers
• Patients with multiple specialist care providers
• Patient with high acuity care‑coordination (e.g. patients with active cancer diagnosis)
• Time intensive patients (as designated by the medical provider).
• Conducts RN‑led chronic care management visits. The RN will review population health data for the panel entrusted to the assigned care team with the Medical Provider.
• Identifies patient care needs based on assessments and conversation with the patient and family.
• Verifies the patient history, medication list, problems, and diagnostic test results and identify any care gaps.
• Monitors and facilitates preventive care such as immunizations, cancer screenings and lab tests.
• Conducts Medication Reconciliation for all High Needs Patients, RN‑led Visits and per provider request. Gives report to provider, using SBAR method, about patient care needs. Collaborates with care team and patient in developing team priorities, patient goals and care plans.
• Assists the patient in setting realistic self‑management goals taking into consideration barriers the patient and family may encounter.
• Assists the patient in obtaining needed services in the community such as transportation, house etc. by referring the patient to the appropriate organization and monitors results.
• Documents in EMR the RN interaction…