RN, Health Coach - Internal Medicine

Job Summary

Assists physicians and clinical staff with clerical/clinical functions for patients requiring chronic disease coordination. Works closely with the Physicians as well as the Practice manager or Chair of the site Quality Council. Utilizes the nursing process to assess patient's condition and direct to the appropriate level of care using internal and external resources. Carries out quality improvement activities and performance improvement initiatives in support of the physician practice.

Essential Job Functions

• Delivers direct and indirect patient care in accordance with the RN Practice Act, hospital and/or physician practice policies, procedures, protocols and other professional standards of care.

• Collects patient health care data, including VS, weight, chief complaint and pain assessment focusing on the physical, psychosocial, age, cultural and spiritual needs of the patient.

• Completes an initial assessment of the patient's health history, learning needs and barriers, physical, psychosocial, cultural and spiritual needs and reassesses annually.

• Involves the patient/ family and other health care professionals when appropriate.

• Completes patient care treatments/testing as ordered by the physician.

• Administers medications/immunizations using appropriate routes and techniques specific to age of the patient.

• Complies with completeness, accuracy and timeliness of documentation.

• Provides education and instruction, within their scope of practice, to patients and families.

• Assesses the patient's readiness to learn, educational needs and educational barriers.

• Provides educational material and/or instruction based on assessed needs.

• Documents all education/instruction provided including topic, individual provided to and understanding.

• Maintains collaborative relationship with physicians to achieve desired patient outcomes.

• Prepares patients for examinations, treatments, and procedures.

• Assists the physician with treatments and procedures as requested.

• Provides for patient safety in compliance with hospital and physician practices policies.

• Utilizes two forms of patient identification before implementing any form of patient care.

• Labels all patient specimens with identifiers per policy.

• Uses patient identifiers on all written documentation, including notes and point of care testing results.

• Assists in compliance with all regulatory agency requirements.

• Adheres to infection control process, including standard precautions, to reduce the risk of acquiring or transmitting infections.

• Participates in non-punitive medication reporting.

• Demonstrates leadership by utilizing the concepts inherent to the practice of professional nursing.

• Demonstrates an ability to solve problems independently and seeks assistance from immediate supervisor when appropriate.

• Maintains accountability for actions taken.

• Delegates patient care appropriately.

• Effectively functions as a resource person.

• Acts as a patient advocate.

• Performs effectively in the role of preceptor/mentor to new hires and/or students.

• Assists in maintaining/decreasing organizational/departmental costs

• Answers and routes multiple telephone calls and faxes, takes and directs messages and information pertinent to chronic disease management. Receives and arranges appointments for providers and patients for patient meetings, procedures, and appointments and sends correspondence as designated.

• Miscellaneous office duties such as greeting patients, answering phone, filing and/or retrieving medical records, and scheduling patient appointments.

• Assists with the clerical operation of office equipment (PC, CRT, printer, copy machine and fax) to effectively and efficiently perform secretarial duties for management purposes.

• Inventories, orders, and receives office supplies and printed materials. Maintains general files and supplies.

• Other duties as assigned.

Specialty Job Functions

• Conducts pre-visit chart review.

• Identifies all needed preventive health maintenance, immunizations, prescriptions and chronic disease interventions.

• Insures Problem lists and medication reconciliation is complete and accurate for all patient visits

• Insures PMFSH is accurate and current for all patient visits

• Assists and coordinates various functionality and utilization of disease registry database including the data entry; assuring database is kept up to date and patient gaps in care are met.

• Identifying patients overdue for visits, labs, referrals, immunizations etc. and follows up to insure gaps in care are closed.

• Identifying patients not meeting clinical and self-management goals and provides guidance to assist with meeting established goals.

• Communicates information to patients and families regarding lab/diagnostic tests.

• Assist patients and families to understand purpose and results of tests.

• Documents information related to tests and results and patient and family understanding.

• Proactively contacts patients to arrange follow-up on process or outcome goals that registry queries show are not being met.

• Document calls, issues and general information in computer database for tracking patient information.

• Assist patients with medication compliance by providing education about the purpose of the medication, directions for use and identification of and /or lessen potential side effects.

• Educate patients about the Excela Health's chronic care program and the importance of meeting their goals and assists with goal setting and plans for behavior change.

• Proactively manages registries and data bases for 100% of patients identified.

• Reinforces physician recommendations and orders as discussed during patient office visits/phone appointments.

• Assists patients schedule referrals as ordered by providers or by protocol.

• Provides education and support to patient and family regarding therapeutic and self-management per patient needs and physician direction.

• Provides follow up support and information to the patient as identified by patients assessed needs or physician instruction.

• Actively participates in practice team and Excela Health communication and performance improvement structure

• Participate in Daily meetings, Team meeting, and interpractice meetings to improve performance.

• Assist in the development of goals and identification of outcomes for continuous quality improvement.

• Supports performance improvement initiatives implemented.

• Maintains complete patient records while keeping complete patient confidentiality.

• Required interventions are documented and communicated to providers or ordered by protocol.

• Documents accurately all interventions on behalf of the patient in the patient medical record

• Actively participates as an integral member of the team in promotion of patient health and wellness

• Collaborates with physician and co-team members to identify needs of individual patients and disease specific populations.

• Provides input into improving patient care by identifying areas of opportunity

• Helps to identify methods to address patient or disease specific population opportunities, education material, group visits etc.

Required Qualifications

• Graduate of an accredited Nursing Program

• Three years of medical experience or equivalent background with a strong understanding of the medical field.

• Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.

• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

Preferred Qualifications

• No preferred qualifications.

License, Certification & Clearances

• Current licensure to practice as a Registered Nurse in the State of Pennsylvania

• Current Basic Life Support (BLS) approved curriculum of the American Heart Association (CPR and AED) program.

• Act 33 with renewal

• Act 34 with renewal

• Act 73 FBI Clearance

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).

• Travel may be expected locally between Excela Health locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one's own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela's missions, vision and values.

AAP/EEO

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.

• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential

• Absolute Necessity.

Marginal

• Minimal Necessity.

Constantly

• 5.5 to 8 hours or more or 200 reps/shift.

Frequently

• 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally

• 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely

• Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Extreme Heat

X

Extreme Cold

X

Heights

X

Confined Spaces

X

Extreme Noise(>85dB)

X

Mechanical Hazards

X

Use of Vibrating Tools

X

Operates Vehicle (company)

X

Operates Heavy Equipment

X

Use of Lifting/Transfer Devices

X

Rotates All Shifts

X

8 Hours Shifts

X

X

10-12 Hours Shifts

X

On-Call

X

Overtime(+8/hrs/shift; 40/hr/wk)

X

X

Travel Between Sites

X

Direct Patient Care

X

X

Respirator Protective Equipment

X

X

Eye Protection

X

X

Head Protection (hard hat)

X

Hearing Protection

X

Hand Protection

X

Feet, Toe Protection

X

Body Protection

X

Latex Exposure

X

Solvent Exposure

X

Paint (direct use) Exposure

X

Dust (sanding) Exposure

X

Ethylene Oxide Exposure

X

Cytotoxic (Chemo) Exposure

X

Blood/Body Fluid Exposure

X

X

Chemicals (direct use) Exposure

X

Mist Exposure

X

Wax Stripper (direct use)

X

Non-Ionizing Radiation Exposure

X

Ionizing Radiation Exposure

X

Laser Exposure

X

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential

• Absolute Necessity.

Marginal

• Minimal Necessity.

Constantly

• 5.5 to 8 hours or more or 200 reps/shift.

Frequently

• 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally

• 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely

• Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Bending (Stooping)

X

X

Sitting

X

X

Walking

X

X

Climbing Stairs

X

Climbing Ladders

X

Standing

X

X

Kneeling

X

X

Squatting (Crouching)

X

X

Twisting/Turning

X

X

Keyboard/Computer Operation

X

X

Gross Grasp

X

X

Fine Finger Manipulation

X

X

Hand/Arm Coordination

X

X

Pushing/Pulling(lbs. of force)

X

X

Carry

X

X

Transfer/Push/Pull Patients

X

X

Seeing Near w/Acuity

X

X

Feeling (Sensation)

X

Color Vision

X

X

Hearing Clearly

X

Pulling/Pushing Objects Overhead

X

X

Reaching Above Shoulder Level

X

X

Reaching Forward

X

X

Lifting Floor to Knuckle

X

Lifting Seat Pan to Knuckle

X

Lifting Knuckle to Shoulder

X

Lifting Shoulder to Overhead

X

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.