• Team-Based Care


• 90 Day Introductory Period with on-boarding support


• Continuous Learning On-The-Job and Internal Training Sessions


• External Training Reimbursed and Paid for Time


• Medical, Dental, and 403(b) Retirement Plan


• Vacation, Holiday and Sick Benefits


• $5000 Sign-On Bonus! Base salary $78,795/year plus bonus incentive.

1. Follows the pre-visit planning policy and procedure as established by the organization.


2. Coordinates pre-visit planning with Medical Assistant and Medical Provider on assigned team.


3. Prepares for, attends and participates in team meetings and huddles.


4. 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 (link removed)pletes screenings for depression, smoking, drugs, safety, etc. per current practice guidelines.


5. 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.

1. 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:
   
   
   
   1. Transfer of Care (TOC) Patients:
      
      
      
      1. New Patients
      
      
      2. Hospital/ER Follow ups
      
      
      
      
   
   
   2. Patients with poor control of chronic medical conditions
   
   
   3. Patients with anticipated barriers to data gathering of patient history and care needs:
      
      
      
      1. Language barriers
      
      
      2. Learning or cognitive disabilities
      
      
      3. Mental Health or Behavioral barriers
      
      
      
      
   
   
   4. Patients with multiple specialist care providers
   
   
   5. Patient with high acuity care-coordination (e.g. patients with active cancer diagnosis)
   
   
   6. Time intensive patients (as designated by the medical provider).
   
   
   
   


2. 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.


3. Identifies patient care needs based on assessments and conversation with the patient and family.


4. Verifies the patient history, medication list, problems, and diagnostic test results and identify any care gaps.


5. Monitors and facilitates preventive care such as immunizations, cancer screenings and lab tests.


6. Conducts Medication Reconciliation for all High Needs Patients, RN-led Visits and per provider request.


7. Gives report to provider, using SBAR method, about patient care needs.


8. Collaborates with care team and patient in developing team priorities, patient goals and care plans.


9. Assists the patient in setting realistic self-management goals taking into consideration barriers the patient and family may encounter.


10. 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.


11. Documents in EMR the RN interaction with patient, according to organizational policy and protocol.


12. Assists provider with procedures as needed and within scope of practice.

Patient Care In Between Visits:

1. Utilizes the EMR and population health tools to identify significant care gaps and take steps to facilitate patient and population management to improve clinical outcomes as identified by clinical quality measures (CQM).


2. Notifies patients, per provider instruction, of abnormal test results and follow plan.


3. Assists the team in monitoring and responding to the Refill Line, per organizational Refill Policy and Protocol.


4. Will be responsible for on-going care coordination of patients as requested by patient (or designated proxy), Medical Provider and other referral entities/diagnostic centers/agencies involved in care of the patient.

General Clinical Responsibilities

1. Provides nursing triage.


2. Medication and vaccine administration.


3. Responds to phone calls in a timely manner and per protocol.


4. Responds to life threatening situations within the scope of licensure.

• Graduate of an accredited school of Licensed Professional Nursing


• Licensed in the State of Hawaii as a Register Nurse.

• 2 years experience as a Registered Nurse, preferred.


• Experience or training in case management, preferred.

• CPR/AED certification BLS


• TB clearance within the past 12 months


• Driver License and access to an insured vehicle


• Proof of COVID-19 Vaccination as required by federal mandate

• Computer knowledge related to word processing, data input, graphs using Microsoft Word and Excel.


• Ability to make accurate assessments and prioritize work to be done.


• Demonstrated excellent assessment skills and performance.


• Ability to solve problems.


• Provide excellent customer services to our clients including demonstration of the organizational value that patient needs are the first and central priority and the belief that patients come first.


• Willingness to assist co-workers.


• Fluency in Tagolog, Ilocano and/or South Pacific Island language a plus.