Under the general direction and supervision of the Director of Nursing. The Clinical Care Coordinator is responsible for facilitating case management services for all patients with a chronic condition. Eligible patients will be ensured that they will receive timely, high quality and efficient health care and support services through the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.
Improve the management and stability of medically complex patients with multiple co-morbidities resulting in reduced ER visits, hospitalizations, treatment-related complications and improved patient quality of life. Increase provider/staff satisfaction by providing care based on planned interactions to support evidence-based care, regular follow-up by the care team and the provision of culturally respectful care the patient understands.
Excellent and competitive benefits package offered which includes medical, dental, vision, disability and life insurance. Company matching retirement plan and generous paid time off to include vacation and sick leave accruals starting from the date of hire.
- Coordinate the care essential to the assessment, promotion, maintenance and restoration of health and wellness for patients with exceptional care needs, defined as patients with two or more of the following diagnosis: Chronic disease, substance abuse, DSM III or chronic pain, all insulin dependent diabetics and patients who require care management between multiple care management team members; family/caregiver(s), payers, and community resources –
- Work with patients to plan and monitor care:
- Assess patient’s unmet health and social needs
- Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
- Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
- Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time
- Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)
- Screen and enroll patients in the Exceptional Needs Case Management Program, ensure appropriate documentation and tracking of patient goals and outcomes;
- Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
- Promote patient engagement and behavioral change through patient education, planned, regular interactions with caregivers;
- Plan with the patient, family, and care team for care that is feasible and within the physical, financial and emotional resources of the individual;
- Develop, implement, evaluate and communicate to the patient/family and care team members plans for managing the patient’s care needs;
- Facilitate referrals to specialist and community resources needed to manage the patient’s care;
- Facilitate communication between patients and their care team including community stakeholders when indicated;
- Coordinate responses to patient needs and suggest solutions to patient care problems;
- Interpret to the patient and family diagnoses and treatment plans at the request of the patient’s Primary Care Provider;
- Teach basic principles and assist patients in managing their chronic diseases through setting self-management goals;
- Provide or assist patients to secure disease specific education as indicated;
- Prepare patient for examination consistent with the purpose of the appointment;
- Respond to phone calls from patients, triage requests and respond according to need; and
- Maintain accurate and legible records of interventions;
- Perform related duties necessary to ensure quality patient care and provider productivity
- Ability to recognize and respect cultural diversity of patients.
- Recognize and respond effectively to verbal, nonverbal, and written communication.
- Ability to follow established policies and procedures dealing with health care.
- Comply with established risk management and safety procedures.
- Able to establish and maintain effective working relationships with the public and health care team.
- Must respect the confidential nature of medical information.
- Working knowledge of standard concepts, practices, and procedures.
- Able to work efficiently and cope with emergency situations.
- Capable of using experience and judgment to plan and accomplish goals.
- Good computer skills and a working knowledge of Microsoft Office.
- Able to read and interpret documents such as charts, safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.
- Professional manner and appearance.
- Emotional and physical health sufficient to meet the demands of the position.
- Ability to work independently and as a team member.
- Ability to organize and prioritize tasks.
- Education: Registered Nurse. Bachelor’s or Master’s degree in Social Work or Nursing preferred
- Unrestricted, unencumbered Texas Nursing license
- Two (2) years’ experience in Care Management/Care Coordination
- Computer skills required (Email, Internet, Microsoft Office – Word, Excel, PowerPoint, Outlook)
- Electronic Health Records (EMR) software
Typical Physical Demands
The physical demands described herein are representative of those that must be met by a staff member to successfully perform the essential functions associated with this position. Because we are committed to inclusion of those with disabilities, reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions associated with their position.
- Carrying: Transporting an object, usually by hand, arm or shoulder.
- Lifting: Raising or lowering an object 25-50 pounds.
- Repetitive Motions: Making frequent movements with a part of the body.
- Talking: Expressing or exchanging ideas by means of the spoken word; those activities where detailed or important spoken instructions must be conveyed to other workers accurately, loudly, or quickly.
|Job Category||Health Care|