Essential Duties:

• Works with Care Coordination RN to promote and reinforce patient centered medical home concepts with patients and staff.


• Work with primary care providers in medical services and informatics team to develop a panel of patients that would benefit from coordination of care.


• Assist in the development of short term and long-term strategies in improvement of patient outcomes and work with the informatics team to track Care Coordination patient outcomes

• Coordinates care of designated patients within the MHM primary care clinic providers, integrated healthcare team, specialists, Care Coordinator team members, Wesley Nurses, patients, and families to facilitate patient through the care system.

• Work with outside agencies for welfare checks and occasionally make home visits.

• Provides education to patient and family regarding patient's condition and ongoing care.


• Responds to calls and questions from patients, providers, and integrated healthcare team.

• Documents tracked outcomes for Care Coordination patients using appropriate terminology and abbreviations.

• Consults with Physician and other health professionals on staff regarding patient care, teaching issues.

• Regularly using the nursing process to assess, plan, implement and evaluate the patient's status, appropriate goals, care provided, care interventions, and patient outcomes.

• Takes and documents patient vital signs (blood pressure, pulse, weight, height, other measures as assigned) both in the clinic and patient's home setting.


• Assists in the resolution of complaints, requests, and inquiries from patients.

• Monitor patients for changes in clinical symptoms in person at clinic, at home or by phone.


• Follows processes implemented to improve patient's health outcomes.

• Assists in the resolution of complaints, requests, and inquiries from clients.


• Performs other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:

High school or general education diploma (GED) and graduate of an accredited Licensed Vocational Nurse program required. Two years of related experience in hospital, clinical setting or related field preferred.

Language Ability:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to read, analyze medical documents. Translate between provider and patient/client. Fluent in English and Spanish required.

Reasoning Ability:

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates and Licenses:

Licensed by the Board of Nurse Examiners in the State of Texas as a Licensed Vocational Nurse. Basic Life Support Certification required.

Computer Skills:

Demonstrates working knowledge of Outlook, Word, Excel applications and electronic health records.

Other:

Must be able to drive and have access to a car; maintain valid driver's license and auto liability insurance.

Work Environment and Physical Demands:

The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the team member is exposed to a medical office environment having direct contact with patients. Position necessitates bending, stooping, twisting, turning, walking, climbing step stools, sitting and standing for periods of time. Must be able to lift and maneuver 25 pounds.