Description

Coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their provider.  Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered.

Requirements

• Current LPN or RN license
• Basic knowledge of chronic disease management (e.g., diabetes, hypertension, COPD)
• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
• Effective organizational skills and demonstrates ability to maintain accurate notes and records.
• Previous experience with health IT systems and data reports preferred
• Ability to multitask and work independently in a rural, fast-paced environment

Summary

JOB REQUIREMENTS:

• Professional attitude, leadership role and team member abilities.  Maintains a positive professional role throughout the facility and community.
• Familiarizes self with and adheres to all facility and department safety policies and procedures.
• Completes all required annual safety training.
• Supports and implements safety into all job responsibilities regarding self, other employees, residents/patients and visitors.
• Safeguarding the privacy and security of protected health information (PHI) in any form including electronic, written or oral.

JOB RESPONSIBILITIES:

• Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
• Implement an effective internal tracking system for identified patients.
• Coach patients/families toward successful self-management of their chronic disease.
• Perform general nursing care to patients.  Administer prescribed medication and treatments in accordance with nursing standards.
• Assess patient and family’s unmet health and social needs.
• Provide effective communications to improve health literacy.
• Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Serve as the contact-point, advocate, and informational resources for patient, family, care team, payers, and community resources.
• Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other NRACO Care Coordinators and Coach).
• Work within ACO platforms for patient coordination per HAMC program already running.
• Greets patients and prepares them for the practitioners’ examination.  Screens patients for appropriate information.  Obtains weight and vital signs of each patient.  Instruct patients in collection of samples and tests.
• Maintains timely flow of patients.  Triage emergent patients, ensuring preferences are given in emergency situations.  Assists patient to the emergency room at HAMC, either by contacting the ambulance when necessary or transporting them by wheelchair/cart when in-house.
• Ensure appropriate information is forwarded to HAMC for deliveries, surgical procedures and admissions.
• Knowledge of supplies and equipment for proper use and care to carry out medical procedures and aid provider during treatment, examination and testing of patients.
• All other duties as assigned.

POSITION COMPETENCIES:

• Core values consistent with a patient/family-centered approach to care.
• Demonstrates professional and effective written and verbal communication skills.
• Demonstrates a positive, respectful attitude and professional customer service.
• Acknowledges patients’ rights on confidentiality issues, always maintains patient confidentiality, and adheres to HIPAA guidelines and regulations.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Recognizes and responds to opportunities for improvement.
• Demonstrates continual learning skills effects changes in approach to care based on established, evidence-based practice.
• Demonstrates professional practice behavior.
• Provides mentoring/coaching of other population health and care coordination team members.
• Cultivate effective partnerships, effectively collaborate with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).
• Demonstrates understanding in use of IT resources and patient databases.
• Demonstrate effective delegation skills to streamline operational workflows and optimize inter-office resources.

TYPICAL WORKING CONDITIONS: 

Work is performed in an office/clinical environment involving contact with physicians, staff, payers, employers and public.  Occasional evening or weekend work and travel required.

TYPICAL PHYSICAL DEMANDS:  Requires full range of motion including handling and lifting patients, manual dexterity and hand-eye coordination. Requires standing and sitting for extended periods of time.  Occasionally lifts and carry items weighing less than 50 pounds.  Requires corrected vision and hearing to normal ranges.  Periodically requires working under stressful conditions.