POSITION SUMMARY:
The Clinical Nurse functions as a member of a progressive, interdisciplinary team. The RN impacts the health of individuals, families and the community through health promotion, disease prevention and chronic disease care including monitoring and evaluating health services and outcomes and documenting services. The RN supports patients, families and the community to achieve their highest level of wellness, to learn to live with or recover from illness, and to enhance their care capabilities and to support their right to make choices. A valued member of the primary care team, the RN is strategically placed to optimize use of his/her/their knowledge and expertise in roles such as clinician, coordinator, consultant, educator for patient, families and students, leader, and advocate.
The RN helps assure that all patients receive high quality comprehensive health care. This position includes, but is not limited to: patient triage, patient assessment, clinical tasks, patient education and counseling, and connection to needed services.
ESSENTIAL DUTIES & RESPONSIBILITIES:
Provide primary care services to patients of all ages, including: phone/walk-in triage, patient education, counseling, family planning activities, coordination of appointments and referrals, assistance in obtaining needed services and supplies. Work collaboratively with the Primary Care Nurse Practitioners and the Primary Care Department and teams to provide comprehensive primary care for all patients. Provide direct patient care activities within the scope of the Registered Nurse including blood pressure checks and hypertension follow-up visits, diabetes follow-up and teaching, other chronic care management visits, emergency department and hospital admission follow ups, medication injections, patient-centered education, and other tasks as delegated and assigned by the Primary Care Nurse Practitioners. Care Manage a designated list of high-risk patients referred by insurance lists, i2i lists, care coordinators, or by a nurse practitioner. These are patients with more than one chronic condition (HTN, COPD, Asthma, CHF, DM1/2, HIV) at risk for hospitalization, and in need of assistance in overcoming psychosocial barriers to care and navigating referrals and follow-up care. Assures quality of care by: adhering to therapeutics standards; measuring health outcomes against patient care goals and standards; making recommendations for necessary healthcare adjustments; Following standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations. Manage and complete refills per the FPCSN Prescription Refill Policy and Procedure. Perform wound care and injection visits, as appropriate. Manage prior authorization of prescriptions, imagine and diagnostic testing as needed in conjunction with the Care Coordinator Collaborate with integrated services such as social services, behavioral health, nutrition, mind/body, and creative arts to provide support and holistic care for all patients. Inform and educate patients about lab results and follow-up plan designated by the Nurse Practitioner. Document patient care services by charting in the Electronic Health Record. Maintain professional and timely treatment communication and documentation; use phone notes and Care Management notes, completing notes in a timely manner. Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; and establishing professional networks. Maintain a cooperative relationship among health care teams by communicating information; responding to request; and participating in team problem-solving methods. Utilize Microsoft Word, Excel (create tracking sheets), and i2i to maintain patient lists and follow-up tasks. Expected to engage individuals in a trusting, supportive and professional relationship, while providing emotional support within professional boundaries. Meet established productivity requirements set by the program guidelines. Participate in health education and promotion activities in collaboration with the Lead Nurse Practitioner, the Practice Manager, and the Center Director/Operations Director. Implement and maintain quality improvement activities related to Primary Care, in collaboration with the Lead Nurse Practitioner, the Practice Manager, the Center Director/Operations Director, and the Quality Manager. Assist and facilitate student experiences in primary care as needed.EXPERIENCE AND REQUIREMENTS:
Candidates should possess a diverse range of skills and experience including but not limited to:
Required Education and Experience
Bachelor’s Degree Preferred
At least 5 years’ experience as a RN; experience in an outpatient practice setting preferred; experience working within OB for pre-natal nurse
Current RN license from the Commonwealth of Pennsylvania
Knowledge of primary health care and the social determinants of health
Required Skills and Abilities
Knowledge of concepts of health promotion, disease prevention, behavior change counseling, program planning, individual and group counseling Nursing care knowledge related to primary care/community health/chronic disease management Excellent organizational skills to manage numerous practice activities Excellent interpersonal skills Proficiency in computer skills, familiarity with Electronic Medical Records and willingness to learn all computer systems Demonstrates initiative, leadership and a high level of nursing skillsUnconditional ability to maintain HIPAA regulationsLeadership skills that include the ability and desire to champion teambuilding within the Primary CareDemonstrates fiscal responsibilityDemonstrates effective time management skills and follow through Support the Center’s commitment to the creation of a trauma-informed system of care that continually recognizes and responds to the impact of traumatic stress on all those who have contact with the organization, including children, adults, families, caregivers, and staff. Uphold the commitments that include: non-violence, emotional intelligence, social learning, open communication, social responsibility, democracy, and growth and change. Specifically: Demonstrate cultural competence/proficiency in interactions with others by treating co-workers, colleagues and those receiving service with respect and fairness at all times. Awareness and sensitivity to the structural conditions and power dynamics involved in systems of oppression embedded in health care that impacts health Ability to build and maintain positive and professional relationships based on respect, trust, and safety. Ability to create a space for staff and those we serve to feel physically and emotionally safe. Ability to support individuals on their paths to recovery and healing and resist re-traumatization of staff and patients. Demonstrate exemplary problem-solving, communication, interpersonal, and conflict resolution skills. Ability to work effectively as a team member Exemplary organizational skills and ability to prioritizeLifting Requirements
LIGHT – Exerting up to 20 pounds of force frequently, and/or negligible amount of force constantly to move objects. The use of arm and/or leg control requires force greater than sedentary, but worker still sits majority of time.
Physical Requirement
Stand or Sit (stationary position)WalkUse hands or fingers to handle or feel (operate, activate, prepare, inspect, position)Climb (stairs/ladders)Talk/Hear (communicate, converse, convey, express/exchange information)See (detect, identify, recognize, inspect, assess)Pushing or PullingRepetitive MotionReaching (high or low)Kneel, Stoop, Crouch or Crawl (position self, move)EQUAL OPPORTUNITY EMPLOYER:
Equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, age, religion, gender, gender identity, sexual orientation, national origin, genetic information, and veteran or disability status.
VISA SPONSORSHIP:
FPCSN does not provide Visa Sponsorship. All candidates must be US Citizens and/or authorized to work in the United States without Sponsorship.
ORGANIZATIONAL COMMITMENT:
FPCSN is committed to maintaining a professional and welcoming environment for all staff and patients. We support continuous learning and team development that enhances cultural understanding, service excellence, and workplace collaboration.
Read LessPOSITION SUMMARY:
The Behavioral Health Access Care Manager is responsible for coordinating and executing all activities related to high-risk and/or increased needs from within the OP Behavioral Health Department. The Access Care Manager works across FPCSN sites and interfaces with Individuals served within OP BH who are experiencing challenging transitions in their care, and/or experience higher resource needs, and performs a range of administrative duties to optimize program outcomes. They support clinical outcomes based on planning and linkage to both internal and external resources on an individualized basis.
Team members are expected to uphold the health center's mission by assuring that Individuals receive health care that is competent, caring, and meets with a high degree of satisfaction. In addition, staff must support FPCSN's commitment to the creation of a trauma-informed system of care that continually recognizes and responds to the impact of traumatic stress, including poverty and racism, on all those who have contact with the organization.
ESSENTIAL DUTIES & RESPONSIBILITIES:
Care Planning: Engage individuals with SPMI in-person or through virtual visits for ongoing care planning to ensure long-term psychiatric medication management for individuals who have graduated from the need for regular therapy. Document care plans for individuals receiving medication only, in accordance with departmental and regulatory standards, ensuring timely signatures from all parties, and submission into their records. Follow-up to ensure receipt and exchange of applicable information to outside BH sources, such as obtaining hospital discharges, attaining/sharing records with other providers, specialists, and collateral contacts, as applicable.Administer structured tools (STs) to assess symptoms and functioning for individuals in ongoing care, under the supervision of a BH provider. Track and upload results of ST data to appropriate system(s), such as within the EHR, Athena. Support managers and providers with BH group recruitment, virtual telehealth platform needs, homework support, and other access-related barriers present for FPCSN clientele to join groups. Transition of Care facilitation and linkages to internal/external resources: Coordinate all components of the OP BH level of care transitions and emergent needs. Support BH Providers with documentation related to referring clients to other levels of care and other BH resources available (i.e., ICMs, etc.) Maintain a discharge tracking list from all psychotherapists that includes dates, insurance, reason for discharge, and aftercare planning.Coordinate Care Outreach activities to ensure linkage to internal and external support and resources detailed in the continuing care plan. Ensure full intake and engagement with the next provider(s). For individuals with SPMI, support linkages and warm handoffs with other internal FPCSN services outside of BH, the person identifies as supporting their goals, including gym, mind/body, nutrition, etc. Conduct needs assessment of patients referred to the programs and develop goals to support BH healthcare access and treatment. This may include assistance with medical assistance, insurance, documentation necessary for care, etc. Outreach will be completed regularly via phone, email, and mail as appropriate. Connect with the network Social Work and O&E team members monthly. Behavioral Health Community Education and Resource Management: Take initiative to research and maintain psycho-educational and social resources and referral streams for clientele and staff. Create centralized resource library folders accessible to staff and community members. Support and develop creative marketing strategies to destigmatize BH for the community. Support in destigmatizing and marketing efforts by tabling for events, such as MH Awareness Month and Suicide Prevention Month. Direct Care: Proactively recognize signs of increased distress in-person or over the phone; respond to immediate crises and identify additional clinical support as needed, provide trauma-informed de-escalation, and debrief with BH manager(s). • Assess risk/ urgency of presenting needs and provide crisis assessment and intervention as needed. Outreach to Individuals with BH needs who are referred by providers for additional support through active listening and other interventions to support individual care goals and needs. Make linkages and suggestions for alternative connections through education, consultation, support, and referrals. Create and ensure signatures and regulations tied to care planning are met for each limited therapy Individual who are followed by a Prescriber. Other duties as assigned.EXPERIENCE AND REQUIREMENTS:
Candidates should possess a diverse range of skills and experience including but not limited to:
Required Education and Experience
MSW, or equivalent experience; LSW or LCSW preferred; Other health disciplines are welcome to apply (LPN, RN, etc.). Program management experience is a plus. Education, training, or experience in working with BH populations. Proficiency in computer skills and willingness to learn all computer systems.Required Skills and Abilities
Program management experience is a plus. Excellent interpersonal, customer service, and problem-solving skills. Team Player. Unconditional ability to maintain HIPAA/confidentiality regulations. Demonstrates cultural competency among persons from various ethnic and social backgrounds. Demonstrated professionalism, responsibility, courtesy, reliability, and effective time management skills. Exhibit behaviors that align with FPCSN’s organizational values, mission, and beliefs, and avoid displaying behaviors that are in opposition to those values. Support FPCSN's commitment to the creation of a trauma-informed system of care that continually recognizes and responds to the impact of traumatic stress on all those who have contact with the organization, including children, adults, families, caregivers, and staff. Ability to build and maintain positive and professional relationships based on respect, trust, and safety. Ability to create space for staff and those we serve to feel physically and emotionally safe. Ability to support individuals on their paths to recovery and healing and resist re-traumatization of staff and patients.Other Qualifications
Ability to pass required background screenings. Required Immunizations: TB/PPD Test. Optional Immunizations: Hep B Vaccination and Flu Vaccination. Current valid CPR Certification required. Maintain current, valid applicable position credentials. Maintain reliable transportation to travel throughout the network and/or participating events outside the network as needed.Lifting Requirements
LIGHT – Exerting up to 20 pounds of force frequently, and/or a negligible amount of force constantly to move objects. The use of arm and/or leg control requires force greater than sedentary, but the worker still sits for the majority of the time.
Physical Requirement
Stand or Sit (stationary position)WalkUse hands or fingers to handle or feel (operate, activate, prepare, inspect, position)Climb (stairs/ladders)Talk/Hear (communicate, converse, convey, express/exchange information)See (detect, identify, recognize, inspect, assess)Pushing or PullingRepetitive MotionReaching (high or low)Kneel, Stoop, Crouch or Crawl (position self, move)EQUAL OPPORTUNITY EMPLOYER:
Equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, age, religion, gender, gender identity, sexual orientation, national origin, genetic information, and veteran or disability status.
VISA SPONSORSHIP:
FPCSN does not provide Visa Sponsorship. All candidates must be U.S. citizens and/or authorized to work in the United States without Sponsorship.
ORGANIZATIONAL COMMITMENT:
FPCSN is committed to maintaining a professional and welcoming environment for all staff and patients. We support continuous learning and team development that enhances cultural understanding, service excellence, and workplace collaboration.
Read Less