At CCI Health Services, our mission is to deliver high-quality accessible care to our community members, leading the way to a more equitable healthcare system for everyone. Our vision is a healthy and empowered community for generations to come. 

　　As a member of the health center’s integrated care team the Lead RNCC fulfills the following KEY FUNCTIONS AND RESPONSIBILITIES for the provision of patient centered, coordinated health care: 

　　Leads the care coordination program to support comprehensive care management, health promotion, comprehensive transitions of care, and referral to social support services. 

　　Supervises care coordination nursing team – including assigning duties, coaching, hiring, training and corrective action. 

　　Monitors population health outcomes against standards and engages in quality assurance and quality improvement activities to suggest improvements related to care coordination and management. 

　　Builds and continually assesses care plans, needs assessments including readiness for change, discharge procedures and monthly disease assessment in the electronic medical record.  

　　Supports preventing disease exacerbation and improving outcomes, increasing patient engagement in self-care, decreasing risk status, and minimizing hospital and ED utilization amongst CCI’s patient population. 

　　Maintains a panel of episodic care coordination and chronic care management patients utilizing behavioral strategies to develop patient-centered care plans, setting patient-centered goals, and continually assessing patient’s self-advocacy, self-management, and barriers.  

　　Develops systems and leads case review and clinical coordination with the clinical care team. 

　　Develops, enforces, and maintains policies, procedures, workflows, and clinical guidelines.  

　　Attends and participates in meetings, committees, health fairs, events and training as assigned.  

　　Consistently seeks avenues for education and trains the care coordination team to maintain compliance with evidence-based practice and advancements in nursing care coordination and management.  

　　Maintains the patient’s electronic medical record within expected timeframes, following CCI standards for charting. 

　　Provides quality customer service and communicates in a HIPAA compliant, culturally sensitive, and trauma-informed manner.  

　　Works within the policies and procedures of CCI Health Services Inc. 

　　Two days of clinical care per week required for this position and may require travel between CCI sites to provide coverage as needed. 

　　Performs other duties responsibilities as assigned by the Director of Nursing or designee. 

　　MINIMUM QUALIFICATIONS: 

　　Active RN license issued by the State of Maryland Board of Nursing or any state under the Nurse License Compact.  

　　Minimum of three (3) years of nursing experience, with care management/coordination experience and progressive leadership experience a plus.  

　　Current BLS/CPR certification required. 

　　Excellent written, verbal, telephone, and interpersonal communication skills with experience documenting in an Electronic Medical Record (EMR). Specific knowledge of eClinicalWorks (eCW) is a plus. 

　　Prior experience in a lead or supervisory capacity a plus. 

　　Written and oral fluency in English.  

　　WORKING CONDITIONS: 

　　Working onsite is an essential duty for the job.  

　　This position may require travel between CCI sites as needed. 

　　Work under stressful conditions within a controlled, enclosed environment daily.  Work environment may involve exposure to potentially dangerous materials and situations that require extensive safety precautions and may include the use of protective equipment.   

　　ADA Category.  In accordance with the American with Disabilities Act, it is possible that requirements may be modified to reasonably accommodate disabled individuals. However, no accommodation will be made which may pose serious health or safety risks to the employee or others or which impose undue hardships on the organization.  

　　OSHA Category 1.  Clinical environment. Possibility of exposure to chemicals and infectious body fluids e.g., HPV, HIV, HEP C, HSV. 

　　Founded in 1972, CCI Health Services is a diverse and inclusive workplace grounded in community. Located in the Washington, DC Metro Area, each year CCI cares for more than 60,000 individuals in Montgomery and Prince George’s Counties. As a non-profit, CCI is committed to improving health equity through the provision of affordable primary care for all, across all stages of life. Visit ccicares.org for more information.

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