Care Management and Education Nurse at Ammonoosuc Community Health Services, Inc. – Littleton, New Hampshire

Under the leadership of the Senior Manager of Clinical Services, the Care Management and Education Nurse is responsible for patient safety, quality, infection control, care management and staff education. Team members will have different areas of focus including transitional care management and staff development, but all members of the Care Management and Education Team will be cross-trained in all of these domains. This role ensures safe, high quality patient care and serves as a clinical resource for direct clinical support staff across ACHS sites.

Care Management and Patient Support:

• Deliver Transitional Care Management (TCM) services for patients following hospital discharge, ensuring timely follow up, care coordination, and reduction of avoidable readmissions.
• May expand responsibilities (as staffing allows) to include:
• Chronic Care Management (CCM)
• Remote patient monitoring support
• Patient education visits (nurse visits)
• Clinic phone triage support
• Respond to patient and clinical support staff needs promptly, identifying and addressing potentially urgent situations
• Utilize critical thinking, nursing judgement and proficient assessment skills to provide appropriate medical advice to patients and staff, including clinical support staff and new patient coordinators as needed
• Collaborate with the Clinical Support Staff Manager to ensure clinical staff have adequate resources and support for safe and effective patient care, including triage and workflow guidance.

Clinical Education and Competency:

• Conduct routine and as needed training, education, and competency assessments for clinical support staff (RNs, LPNs, MAs, LNAs).
• Assist in developing, implementing, and reinforcing clinical standards, workflows, and best practices.
• Participate in onboarding of clinical support staff and ensure competency validation per ACHS policy.
• Identify learning needs and partner with leadership to create improvement plans or targeted training.
• Collaborate with clinical leadership and clinical support to ensure adherence to the highest standards of patient safety and clinical quality

Clinical Resource and Collaboration:

• Serve as a knowledgeable clinical resource for support staff, addressing questions related to scope, procedures, protocols, and patient care needs.
• Support interdisciplinary communication to promote a culture of clinical excellence and teamwork.
• Provide in clinic coverage for providers as needed during staffing shortages or peak demand.
• Educate patients and their families on disease management, treatment plans, and preventive care
• Assist in scheduling appointments, referrals, and follow-up visits

Other Responsibilities:

• Contribute to patient safety, quality, and infection control initiatives as requested by manager.
• Support documentation, reporting, and process improvement efforts related to TCM, CCM, education, and clinical operations.
• Other duties, site assignments, and schedule adjustments may be required based on organizational needs.