DEFINITION

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

JOB ESSENTIALS

• 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.
• Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
• 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.
• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
• 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 resource for patient, family, care team, payers, and community resources.
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records).
• Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.
• Attend and actively participate in all Care Coordination related training and meeting activities
• Demonstrates a positive, respectful attitude and professional customer service.
• Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice.
• Provides mentoring/coaching of other population health and care coordination team members
• Cultivates effective partnerships, effectively collaborates 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.
• Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

Minimum Requirements

• Current licensure as a Registered Nurse OR current licensure as a Licensed Practical Nurse required
• Previous experience in caring for chronic disease patients required.
• Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
• Proficient in communication technologies (email, cell phone, etc.).
• Effective organizational skills and demonstrates ability to maintain accurate notes and records.
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.

Preferred Requirements

• 3-5 years’ experience in clinical or community health settings preferred.
• Previous Care Coordination, Case Management or Home Health experience preferred.
• Previous experience with health IT systems and data reports preferred.
• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
• Ability to speak a relevant second language preferred.

Physical Requirements

Perceive the nature of sounds by the ear, express or exchange ideas by means of spoken word, perceive characteristics of objects through the eyes, extend arms and hands in any direction, seize, hold, grasp, turn, or otherwise work with hands, pick, pinch, or otherwise work with fingers, perceive such attributes of objects or materials as size, shape, temperature, or texture; and stoop, kneel crouch, and crawl. Must be able to lift 25 pounds maximum with frequent lifting, carrying pushing, and pulling of objects weighing up to 10 pounds. Continuous walking and standing. Must be able to identify, match, and distinguish colors.