Care Plan-RN

Job Description

Job Description

Position Summary

The Care Plan Nurse – RN serves as a key advocate and care coordinator for patients within the Patient-Centered Medical Home (PCMH). This role provides comprehensive support across the continuum of care, focusing on disease prevention, chronic disease management, patient education, and improving overall health outcomes.

Key Responsibilities

Collaborate with healthcare team members to develop, implement, and evaluate patient care plans.

Direct and assist the primary care team in addressing clinical, health, and psychosocial needs.

Coordinate patient education, appointments, and referrals, including nutritional and health visits.

Identify patients for care management, assess care requirements, and intervene as needed.

Document patient progress and education in the Electronic Health Record (EHR).

Provide patient education on chronic conditions, medication management, and preventative care.

Monitor quality improvement measures and participate in Payer Incentive Programs.

Maintain compliance with federal, state, and programmatic regulations.

Support quality improvement initiatives and PCMH activities.

Act as a liaison for Family Circle of Care and community resources.

Provide coverage for clinic duties or telephone triage, as assigned.

Patient-Centered Responsibilities

Monitor patient comfort, safety, and clinical needs.

Conduct assessments, obtain vital signs, and record nursing histories.

Notify providers of changes in patient conditions and responses to treatment.

Encourage patient engagement in their care through self-management education.

Supervisory Responsibilities

Provide guidance and technical expertise to clinical staff (LVNs, MAs, CCMAs).

Assist the Quality Improvement Director in training, performance appraisal, and problem resolution.

Qualifications

Education : Bachelor of Science in Nursing required.

Experience : At least 1 year of nursing experience in a clinical or hospital setting preferred.

Licensure : Current RN license (or GN permit) in the state of Texas. Must maintain licensure, CEUs, and certifications as required.

Certifications : Current BCLS Healthcare Provider Card (renewed every 2 years).

Technical Skills : Proficiency in Microsoft Word, Excel, and EHR systems; EPIC experience preferred.

Equipment : Experience with point-of-care testing equipment (e.g., glucose meters, BP monitors).

Core Competencies

Strong communication and patient advocacy skills.

Ability to lead and collaborate within a team environment.

Demonstrated knowledge of chronic disease management and preventative care.

Commitment to ethical standards, diversity, and cultural sensitivity.

Strong organizational and problem-solving abilities.

Why Join Family Circle of Care?

At Family Circle of Care, you’ll be part of a growing healthcare organization recognized for its leadership in patient-centered care. We are dedicated to innovation in chronic disease management, preventative health, and community wellness. Our team is mission-driven, collaborative, and passionate about making a difference, giving you the opportunity to work in a supportive environment where your skills and compassion truly impact patients’ lives.