Care Coordination Coordinate and facilitate patient centered interdisciplinary care and communication, including home health and referring physicians' around interventions leading to the best outcome. Provide regular and consistent follow-up during transitions of care with patient, coordinators and other healthcare professionals in other care settings; including Care Navigators and Patient Care Facilitators.
Demonstrates competence in the skills necessary to carry out assigned duties. Education Coach and educate designated patient population and family regarding chronic disease self-management and preventative health maintenance using predefined protocols and evidence based medicine.
Work with patients and families to develop and work towards self-management goals through RN only visits. Empower patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary utilization. Provide consolidated information regarding internal and external resources and services including home health and other community support services to patients/families as well as the healthcare team.
Disease Management Support provider in meeting chronic and preventive health care needs by guiding patients in collaborative self-management. Proactively assist providers and other healthcare team members as patient advocate, ensuring progress toward goal attainment. Population Health Utilize patient registry tools to guide action plan for designated patient populations.
Identify high-risk patients and intervene with the guidance of the provider to improve outcomes. Leadership Demonstrate clinical leadership as a role model for other staff and provide direction that ensures top of licensure duties for all team members. Utilize critical thinking in making independent judgments related to patient care.
Maintain responsibility and accountability for the knowledge of conditions of assigned patient populations. Engage in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided. Professional Qualities and Attributes:
Demonstrate flexibility and adaptability, priority setting, problem solving, conflict resolution, decision-making, work delegation and organization. Must be highly motivated and self-directed. Must be able to communicate effectively with people of diverse professional, educational and lifestyle backgrounds.
Ability to understand and apply protocols, policies and procedures. Ability to work independently and assume responsibility for timely completion of assigned functions. Strong computer skills, interpersonal skills, clinical proficiency and ability to work as part of a multi-disciplinary team.
Graduate of an accredited program for Registered Nurses, Current license to practice nursing in the state where care is provided.
Mandatory Reporter certification. CPR certification.
Achieve and maintain certification in Integrated Care Management within 6 months of hire. The organization will fund one class of Integrated Care Management which includes examination. Additional course work and/or exam fees will be the responsibility of the employee.
Meets educational/competency requirements per policy.
Bachelors of Science in Nursing (BSN) preferred
Previous clinical experience in a medical office, process improvement, and Care Coordination experience preferred.