["Care Coordinator","Care Coordinator"]

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. 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.

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 withinthe 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.