Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking a GLFHC is currently seeking a Registered Nurse, Clinical Care Nurse Coordinator (CCNC) to serve as an integral member of the healthcare team to improve the clinical and operational performance for a select group of high risk patients. The Clinical Care Nurse Coordinator role will focus on organizing, planning and coordinating the delivery of care as provided by the healthcare team at the direction of the PCP. They will manage and operationalize the integration of care in order to promote and improve health outcomes for the subset of high risk patients; patients who often have a chronic disease. They will focus on making the right care available to the patient at the right time.

Job Responsibilities:

• Works collaboratively with Medical Services, Nursing Department, Operations and Information Technology and other departments’ leadership to implement PCMH elements.
• Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets (i.e. immunizations, consults age-appropriate preventive screening such as mammograms, colonoscopy, smoking cessation counseling).
• Communicates with internal and external care providers to ensure safe and effective care management.
• Assesses progress toward goals based on clinical judgment, review of patients’ self-monitory tools and trends in clinical data (i.e. HbA1c, LDL, BP).
• Assists with the timely follow-up and coordination of care for patients discharged from a hospital or other healthcare organization in the continuum.
• Reviews, analysis and utilizes data and trends from relevant reports to determine if care coordination has improved patient status.
• Participates in quality improvement activities, assisting in the design and implementation of multifaceted projects.
• Engages in and facilitates other initiatives as assigned that may cross sites or disease process that align with the PCMH (Patient Centered Medical Home) model.
• Regular and routine travel between clinic sites, patient homes, and to community facilities will be required with occasional travel in inclement weather.

Qualifications:

• Prior experience in a Patient Centered Medical Home strongly preferred.
• Familiarity with computerized data management and research protocols.
• Sound analytical and computer skills required.
• Strong verbal and written skills required.
• Spanish fluency strongly preferred.

Education:

• Graduate of an accredited professional nursing program with current Massachusetts Registered Nurse license
• Bachelor’s degree in nursing or related field required.

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.