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RN Condition Care Programs


Posted: 10/2/2019
Job Reference #: 5000399392406
Keywords: nursing

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

Works with physicians, Provider Organizations, health care facilities to support their patients by utilizing the nursing process, behavior change theory, motivational interviewing (MI), critical thinking and clinical knowledge to identify health risks, develop appropriate action plans, and engage their patients in creating awareness to close gaps and reduce potential health risks.

Driving Required (50% or more of the essential duties in the job description requires traveling offsite).

Minimum Qualifications

  1. Bachelor's (BA) degree and three years of related work experience in a clinical environment to include physician's office, hospital, long term care or hospice facility; or equivalent combination of education and work experience.
  2. Active RN license in the State of Hawaii
  3. Must meet facility specified health screening requirements
  4. Good working knowledge of Microsoft Office applications, includes Outlook, Word, and Excel
  5. Must have valid driver's license, access to an automobile with current license, registration and no fault insurance
  6. Documentation skills, analyzing information, decision making, research skills, verbal communication, written communication, interpersonal skills, resolving conflict, and integrity.
  7. Well organized, ability to multitask and work independently to promote flexibility and teamwork.
  8. Effectively work in a fast paced environment and adjust to rapid change
  9. Provide excellent customer service to external and internal customers.
  10. Excellent analytical and problem solving skills in order to judge medical necessity and appropriateness of patient services and treatments on a case by case basis.
  11. Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
  12. Maintains confidentiality of patient information according to Federal (HIPAA), organizational, and departmental policies.
  13. Ability to communicate effectively with providers and other health care team and develop strong and collaborative working relationship

Duties and Responsibilities

  1. Case Load Management
    • Effectively manages a case load of patients to support, educate and guide patients towards well-being with goals being appointment adherence, medication adherence, self-management, and improved clinical outcomes.
    • Adhere to quality standards for management, documentation, and communication.
    • Effectively works with physicians and/or other healthcare professionals to build an individualized care plan, utilizing interpersonal and nursing skills Utilizes active listening skills and personalizes the message in a way that resonates with the physicians and their patients.
    • Leading collaboratively to establishes a plan of care with the member, physician, and/or other healthcare professionals taking into consideration the members' readiness to change. Develops nursing interventions to address specific gaps/risks. Prioritizes short and long-term goals and outcomes.
    • Documents and tracks outcomes in the clinical information system and other tracking systems.
    • Determine and services every patient uniquely while maintaining privacy.
    • Provide face-to-face or telephonic support to reduce or eliminate high-risk behaviors and improve clinical outcomes by applying evidence-based strategies and guidance in sessions for adoption of specific behaviors that are proven effected by research. This is achieved in both group and individual sessions.
    • Stays current with evolving best practices, clinical practice guidelines, medications, disease state, and patient tools and technolog
  2. Documentation:
    • Leverages self-reported information, claims data, and health records to complete the assessment. Uses clinical skills to integrate all available data in order to quickly determine member's needs in the development of a clinically appropriate plan of care.
  3. Patient Communication and Engagement:
    • Provides evidence-based interventions in layman's terms and helps the member understand the relevance to their health situation.
    • Facilitates the member's growth toward becoming an empowered and engaged health-care consumer through self-management skills that include but are not limited to: having relevant action plans, understanding the criteria for their activation, and understanding when to contact their physicians for new or worsening symptoms to prevent further deterioration.
    • Coordinate with other team members, physicians, and external vendors to ensure participants access the services and programs they need to optimize their care.
  4. Employee Engagement and Relationships:
    • Functions as an integral part of the multi-disciplinary team
  5. Other duties as assigned