Harlem Hospital Center has been a bedrock of the Harlem community since 1887. The hospital provides a wide range of medical, surgical, diagnostic, therapeutic and family support services to the residents of Central Harlem, West Harlem, Washington Heights and Inwood. Harlem is the largest hospital in the area, capable of treating the most seriously ill. Harlem provides over 90 specialized ambulatory care services, dentistry and oral surgery, behavioral health services, and community substance abuse treatment.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

Under general supervision, with latitude for independent judgment and initiative, assists in the planning, organizing, and coordinating the care of patients participating in any of Harlem's ambulatory care quality improvement programs. This position is broadly responsible for the outreach and coordination of care for patients assigned to Harlem's primary care practices, for those assigned as ACO patients, for high risk patients, and for those who are seeking primary or specialty care at Harlem. The position primarily supports the Diabetes Self-Management Education(DSME) program, and ongoing certification of our Patient-Centered Medical Home.

SUMMARY OF DUTIES AND RESPONSIBILITIES:
• Conducts outreach to patients due for clinic visits for programs including but not limited to:
• ACO (Accountable Care Organization)
• PCMH (Patient Centered Medical Home) high risk groups
• DSME program
• Incoming Referrals to Primary Care
• Incoming referrals for Chronic Disease Management
• Care Gaps
• The role supports primarily but not only patients with diabetes
• Conducts reminder calls and care coordination for particular specialties in Ambulatory Care.
• Participates in ACO, PCMH, and Care Gap meetings to update teams on strategy and progress of outreach and closing of gaps.
• Conducts chart reviews and updates/maintains spreadsheets and records to support continuing certification of the DSME program, PCMH, and closure of Quality Care Gaps.
• Leads individual and group patient education around diabetes self-management.
• Conducts patient-education and navigation in the primary care practice to help close care gaps for patients (mammography screening, colorectal cancer screening, tele-retinal screening, etc.)
• May participate in direct patient care as needed (hemoglobin a1c measurement and counseling, blood pressure measurement and counseling, dietary counseling, vaccine counseling)
• The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent to the position.
• Additional duties assigned.

Minimum Qualifications
1. A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and
2. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).

Special Note:
For assignments in Post-Acute Care ONLY, individuals meeting the following criteria may also be considered for appointment: Graduation from a nursing education program registered by the New York State Education Department (NYSED) as licensure qualifying for Registered Professional Nurse (RN) and has applied for licensure as an RN. These unlicensed individuals may be employed to practice under the immediate and personal supervision of a NYS licensed, currently registered, RN for up to 90 days immediately following graduation pending receipt of a limited permit, which selected candidates must apply for and receive within the same 90-day period. Once a limited permit is received, individuals can practice nursing, under the immediate and personal supervision of a NYS licensed, currently registered, RN at a NYC Health + Hospitals health care setting for up to one (1) year from the date of issuance of the limited permit. In addition, must hold or obtain through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs