Chronic Care Lead Nurse
4 weeks ago
ABOUT THE COMPANY
Avenue Hospital was founded in 1995 for the purpose of managing the outpatient department at the Hospital, and to extend medical services to corporate clientele through an innovative concept of Managed Healthcare.
Our Purpose
Our purpose is to maintain and enable health
Our Mission
To provide high quality medical care that exceeds the needs of our clients
Our Culture and Core Values
Respect - For all human beings regardless of financial status, race, tribe, national origin, religious or political beliefs
Service - Providing the best service to our patients, their families, doctors, clients, business partners and staff
Excellence - Continually striving to improve and achieve excellence in the provision of our services
JOB SUMMARY
Person SpecificationGraduate of an accredited nursing school as a Registered Nurse with a valid license with the Nursing Council of Kenya.Updated BLS, ACLS/ATLS certificateMinimum of 3-6 years work experience in a healthcare setting involving patients with complex chronic disease states preferred.Customer focus, empathetic and emotional intelligenceStrong interpersonal and communication skillsOrganizational awareness and attention to detailTeam work and result orientedEthical and reliable
RESPONSIBILITIES
1.Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner.2.Responsible for registry of chronic care management (CCM) to patients.3.Validates enrollment of CCM patients based on provider request4.Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR.5.Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.6.Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.7.Facilitates patient access to appropriate medical and specialty providers.8.Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates9.Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education10.Educates patient and family/caregiver(s) about relevant community resources.11.Assist with the identification of "high-risk" patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.12.Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.13.Supports patient self-management of disease and behavior modification interventions.14.Provides patient health counseling, education and instruction.15.Any other duty assigned by your immediate supervisor in line with the job description.
REQUIRED SKILLS
Following care plans, Medication and prescription administration, Patient care, Quality control and supervision, Medicine, Documentation and record keeping
REQUIRED EDUCATION
Bachelor's degree
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