Care Coordinator

Job Summary:

• Responsible for direction of patient care in the outpatient care setting.
• Consulting with staff, providers and Nurse Manager on nursing problems and interpretation of clinical policies to ensure patient needs are met.
• Maintains performance improvement activities within the department and participates in CQI activities.
• Assist Nurse Manager, providers and staff in the coordination of care for the patient population.
• This Care coordination includes; assisting patients with establishing appointments outside the Patient Centered Medical Home (PCMH), send referrals, establish co-management agreements and track the course of the patients care to ensure proper follow-up, and help to remove any barriers to care.

DUTIES AND RESPONSIBILITIES:

• Coordination Consult with other departments, as appropriate, to collaborate in patient care and performance improvement activities.
• Participate with care team in coordination of patient care according to Priority Health Care policies and procedures.
• Effectively facilitate daily huddle for care coordination and continuity of patient care.
• Manage patient testing, notify provider of IMAGING/X-ray results and communicating provider instructions to the patient.
• REVIEW LAB RESULTS IN CONJUCTION WITH PROVIDER REVIEW.
• Effectively build and manage partnerships/relationships with outside sources to promote continuity of care.
• Coordinates and directs patient care to ensure patients’ needs are met and clinical policies are followed.
• Communicates with local hospitals, specialists and insurance plans to ensure proper follow up after hospital admission, Emergency Department visit, OR CONSULTATION.
• Maintain accurate and continued nursing documentation including patient history, condition, treatment, responses and assessment of changes.
• Provide recommendation and/or completes evaluations as indicated, and submit in a timely manner to the Nurse Manager for review.
• Communicate appropriately and clearly with Nurse Manager, providers, and other team members.
• DIRECT-CARE Management of high-risk populations care Assist patients with in-house referrals within two days.
• Education of patient population relating to community resources and ensure proper coordination with CMO, providers, staff and outreach workers to eliminate barriers to care for patient population.
• Contacts patients in pre-visit preparation before upcoming appointments.
• Follow up with patients/families who have not kept important appointments.
• Assist patients in promotion of self-management tools.
• Adequately assess and reassess patients with chronic diseases.
• Utilizes appropriate disease management techniques.
• Educate patient and family regarding disease process.
• Ability to formulate an individual plan of care, as indicated and evaluate plan for effectiveness.
• Formulate a teaching plan based on identified patient learning needs, and evaluate effectiveness of learning as appropriate.
• As directed by provider, perform waived testing Communicate results to provider and take appropriate action as directed by providers or standing order.
• Assist providers and team members with patient procedures.
• Communicate routinely with patients to ensure compliance with visits and medications as appropriate to disease.
• Interact professionally with patient and family.
• Involve patient and family in the formation of the plan of care.
• Treats patients and families with respect and dignity; identifies and addresses psychosocial needs of patients and family, Practice good guest relations.
• FOLLOW-UP Identification of hospital admissions, hospital re-admissions, emergency room visits and ensuring proper follow-up of patients.
• Execution and tracking all patient testing and referrals for assigned location in accordance with PHC policies and procedures.
• Maintain ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety.
• Ensure referral tracking is completed electronically through the electronic medical record.
• EDUCATION Stay up to date on community resources that are available to patients to promote holistic health and promote patient involvement in plan of care.
• Make decisions that reflect professional knowledge of facts, knowledge of disease/surgical conditions, care required and good judgment.
• Knowledge of medications and correct dosing and administration, based on age of patients and clinical condition.
• Follows the five (5) medication rights and reduces the potential for medication errors.
• Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patients served.
• Interpret data about the patient’s status in order to identify each patient’s age specific needs and provide care needed by the patient group.
• Manage and operate equipment safely and correctly.
• Performance must reflect knowledge in all areas of care specific to treatment.
• Manage and perform all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

PROFESSIONAL REQUIREMENTS:

• Adhere to dress code, appearance is neat and clean.
• Be flexible, organized and function effectively under stressful situations.
• Completes annual education requirements.
• Maintains regulatory requirements, including all state, federal and JCAHO/AAAHC/NCQA Maintains and ensures patient confidentiality at all times.
• Reports to work on time and as scheduled.
• Wears identification while on duty.
• Works at maintaining a good rapport and a cooperative working relationship with Physicians, departments and staff.
• Represents the organization in a positive and professional manner.
• Attends CQI and Care team meetings, as appropriate.
• Complies with all organizational policies regarding ethical business practices.

REGULATORY REQUIREMENTS:

• Graduate of an accredited school of nursing with care management/ambulatory care experience preferred.
• Current LPN license within the state of practice.
• Current BLS certification.

LANGUAGE SKILLS:

• Able to communicate effectively in English, both verbally and in writing.
• Additional language preferred.

PHYSICAL DEMANDS:

• PHC will comply with the Americans with Disabilities Act, including the Americans with Disabilities Act Amendment Act, and all other Federal, State, and local legislative requirements.
• PHC will ensure that reasonable accommodations are made to enable a qualified individual with a disability to perform the essential functions of that position.

WORK ENVIRONMENT:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
• Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually moderate.
• This job description includes the major duties and responsibilities of the job but is not inclusive of every task inherent to the job.
• In addition, it may be occasionally necessary for employees to be assigned tasks not specifically covered by their permanent assignment.
• Employees will be expected to comply with reasonable requests from their supervisor.
• In the course of performing the job, this position typically spends time sitting, standing, climbing stairs, walking, carrying (15lbs), and lifting (15lbs).
• Coordinate multiple tasks simultaneously.
• Perform repetitive motion activities.
• Operates a computer keyboard, adding machine; firm/strong grasping required.
• Makes and receives telephone calls.

Daily use of general office equipment:

• copier, fax machine, phones, etc.
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