Care Coordinator

InnovaCare Partners, LLC

General Summary of Duties:

Promotes and restores patients' health by completing the nursing process; collaborating with physicians and multidisciplinary team members; providing physical and psychological support to patients, friends, and families. In order to decrease ER and hospital re-admissions for our patients, a Care Coordinator works hand in hand with our primary care clinicians to prepare them for follow-up post hospitalization.

Typical Physical Demands:

Requires full range of body motion including manual and finger dexterity and eye-hand coordination. Requires standing and walking for extensive periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours. Requires exposure to communicable disease or body fluids.

Typical Working Conditions:

Frequent exposure to communicable diseases, toxic substances, and other conditions common to a clinic environment.

Job Duties:

• Identifies patient care requirements by establishing personal rapport with potential and actual patients and other persons in a position to understand care requirements.

• Reviews the daily hospital census for in-patient admits and ER visits.

• Weekend census is reviewed on Monday

• If patient was discharged on the weekend, hospital records are reviewed and note sent to the primary care clinician.

• Visit patents in hospital to assist with discharge care and transition of care

• Work with hospitalists and discharges planner to post hospital care need

• Ensure post hospital visit is scheduled with the PCP

• Document the CC admission and discharge template

• Admission and discharge diagnosis

• Abnormal test results

• Medication changes

• Consult template- by whom

• Discharge plan- home vs. SNF

• Follow-up calls post hospital to ensure office visit is scheduled and if patient fails to complete an office visit there will be additional outreach.

• Calls documented in Outreach template

• Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.

• Promotes patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions.

• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.

• Resolves patient problems and needs by utilizing multidisciplinary team strategies.

• Maintains safe and clean working environment by complying with procedures, rules, and regulations; calling for assistance from health care support personnel.

• Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.

• Documents patient care services by charting in patient and department records.

• Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs.

• Maintains patient confidence and protects operations by keeping information confidential.

• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.

• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem-solving methods.

• Contributes to team effort by accomplishing related results as needed.

Job Requirements:

• Experience with EHR a must as well as basic computer skills.

• Knowledge of professional nursing theory and practice to give and evaluate patient care.

• Knowledge of organizational policies, regulations and procedures to administer patient care.

• Knowledge of medical equipment and instruments to administer patient care.

• Knowledge of common safety hazards and precautions to establish a safe work environment.

• Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care.

• Ability to assess the specific age-related needs of patients.

• Skill in preparing and maintaining records, writing reports, and responding to correspondence.

• Skill in establishing and maintaining effective working relationships with patients, medical staff and the public.

• Ability to react calmly and effectively in emergency situations.

• Ability to interpret, adapt, and apply guidelines and procedures. Ability to communicate clearly.

Preferred:

Strong problem-solving skills and ability to recommend solutions, the ability to listen and communicate effectively, empathy and leadership capabilities. Studies in mental health and/or industrial psychology a plus.

Education:

Graduate of an accredited school of nursing.

Experience:

Three years of experience in a healthcare environment.

Certified/License: Current MA License