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Patient Care Team Nurse (RN)

Department: Medical
Location: Michigan City, IN

Under general supervision and in accordance with established department policies, procedures, care protocols, and provider orders, this position will work within the Patient Centered Medical Home model to systematically analyze patient health information to identify and coordinate the care needs of the individual patient focusing on the continuity of care. This position is responsible for oversight to manage and track coordination of pro-active care for patients with chronic conditions as well as identify wellness and/or preventative service for clinical patients.


  • Graduate of an accredited School of Nursing
  • Bachelor of Science in Nursing preferred but not necessary
  • Registered Nurse licensed in the State of Indiana
  • Current CPR certification


  • One year ambulatory or public health nursing experience is preferred

Skills/Job Requirement

  • Strong organizational and time management skills
  • Proven computer and database management skills
  • Cultural sensitivity
  • Strong assessment skills required
  • Excellent interpersonal and communication skills
  • Leadership and organizational skills essential
  • Correct English usage, spelling and grammar


  • Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentation.
  • Collaborate with the healthcare team to insure continuity of patient care throughout the healthcare settings.
  • Promote effective communication among healthcare team members including patient, family and significant others.
  • Perform assessment, data collection, obtain, review and analyze information in collaboration with the healthcare team members and others as appropriate.
  • Conduct pre-visit planning by reviewing charts, following up on labs, and referrals as well as obtaining necessary orders from the provider.
  • Identifies patient problems, physiological and psychological changes, deviations from normal, and identifies inter-relationships of problems, reports changes to health care providers
  • Keeps care coordination records up to date
  • Initiates, implements, and documents patient and family teaching and documents their response to teaching.
  • Identifies unsafe patient environment and intervenes responsibly.  Discusses situations with Pediatricians and Nurse Practitioners for development of emergency plan for patient and family regarding their health care
  • Maintains open communication with Pediatrician, Nurse Practitioners, and other staff, reporting patient progress, abnormal diagnostic/assessment data, and notable health changes
  • Assists patients and families in functioning at their optimum level.
  • Regularly meets with Providers and other Patient Centered Medical Home team members to identify clinical problems and helps initiate appropriate solution.
  • Assist in implementing and carrying out continuous quality improvement programs and activities.
  • Coordinate services for patients and families utilizing other health related agencies and resources.  Obtains referrals to other physicians and specialists.
  • Follows approved protocols/standing orders for patient care.
  • Ensures that a productive and efficient patient flow occurs.
  • Attendance is an essential function of the job.

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