Basic Job Functions
Provides clinical triage, health education, and comprehensive care coordination for select patients with chronic diseases and complex diagnoses
Delivers direct nursing care for patients of all ages in primary care setting, including medication administration, immunizations, and clinical procedures
Supports mother-baby clinic operations including postpartum and pediatric care
Collaborates with multidisciplinary care teams to ensure coordinated, timely patient care and optimal outcomes
Conducts comprehensive assessments and develops person-centered care plans addressing clinical, social, and environmental needs
Serves as patient advocate and primary liaison, facilitating navigation of healthcare systems and community resources
Manages referrals to specialists, community resources, and social services while navigating insurance coverage
Maintains accurate documentation in electronic health records and care management systems
Administrative
Implements evidence-based care protocols for preventive services, care gap closure, and chronic disease management
Ensures compliance with organizational policies and regulatory standards
Participates in community outreach and population health initiatives
Supports walk-in and urgent care needs within scope of practice
Develops and delivers health education programs for diverse populations
Maintains professional competency through continuing education and certification requirements
Clinical
Provides direct clinical support, health education, and appropriate referrals across multiple care settings
Conducts telephone triage and patient education with clinical decision-making support
Identifies and addresses barriers to care including social determinants of health
Utilizes advanced communication and conflict resolution skills in patient interactions
Provides culturally sensitive care and education materials to diverse populations
Maintains adherence to HIPAA regulations and patient confidentiality
Provides culturally sensitive care and education materials to diverse populations
Maintains adherence to HIPAA regulations and patient confidentiality
ESSENTIAL JOB FUNCTIONS
Local travel for professional meetings, training sessions, community events, and outreach activities
Ability to operate a motor vehicle safely and maintain valid driver's license and insurance
Advanced proficiency in electronic health record (EHR) systems and case management software
Competency in Microsoft Office Suite including Word, Excel, PowerPoint, and Outlook
Skilled in data entry, analysis, and reporting using healthcare information systems
Ability to adapt to emerging healthcare technologies and software platforms
Exercise independent clinical judgment and critical thinking in complex patient situations
Demonstrate exceptional assessment and decision-making abilities with minimal supervision
Demonstrate effective verbal and written communication skills with patients, families, and healthcare teams
Maintain accurate, comprehensive, and timely documentation in compliance with regulatory standards
Manage multiple priorities and cases simultaneously while maintaining attention to detail and flexibility to adapt to changing priorities
Adapt to changing healthcare environments and organizational needs in fast-paced clinical setting
Direct patient contact with diverse populations with potential exposure to infectious diseases
Qualifications and Education Requirements
Education
BSN preferred (RN with Associate degree considered with relevant experience)
Current RN license in good standing in the State of North Carolina
Experience
Minimum 2 years clinical nursing experience, preferably in primary care, community health, family practice, or federally qualified health centers (FQHC)
Case management or care coordination experience preferred
Community Health or Managed Care experience
Experience working with underserved populations preferred
Maternal/child health experience preferred
Certifications
Current CPR/BLS certification
Valid driver's license and insured automobile
Knowledge and Skills
Clinical competence in disease management and case management principles
Strong organizational and time management skills with ability to work independently
Ability to work independently and as a member of the care team
Excellent written and verbal communication skills
Proficiency in Microsoft applications and electronic health records
Cultural competency and sensitivity to diverse patient populations
Must be able to work a flexible schedule including some evenings and weekends
Commitment to serving uninsured and Medicaid patients
PREFERENCES
Bilingual in Spanish strongly preferred.
Knowledge of services available in the community and community partnerships.
Knowledge of barriers to health care for the low-income, uninsured population and experience with addressing the social drivers of health
Additional certifications in specialty areas (diabetes education, chronic disease management)
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