Location/Department: Physician's Center - Primary Care
80 hours per pay period - benefit eligible
Job Summary:
The Care Coordinator works in collaboration & continuous partnership with chronically ill or “high-risk” patients & their families, clinic/hospital providers & staff, & community healthcare resources in a team approach to: promote timely access to appropriate care; increase utilization of preventative care; reduce ED utilization & hospital readmissions; increase comprehension through culturally – & linguistically – appropriate education; create & promote adherence to a care plan, developed in coordination with the patient & the patient/family; increase continuity of care by managing relationships with tertiary care providers, transitions-in-care & referrals; increase patients’ ability for self-management & shared decision-making; provide medication reconciliation; connect patients to relevant community resources; with a goal of enhancing patient & family health & well-being, increasing patient satisfaction & reducing costs.
Supervisory Responsibilities: None
Duties/Responsibilities:
- Uses only approved abbreviations.
- Understands patient safety goals & actions taken.
- Uses 2 patient identifiers before giving treatments, demonstrates process.
- Understands read back of verbal orders/critical lab values & can state process.
- Understands procedure to clarify physician orders.
- Uses standing orders when indicated.
- Accurately calls report to MD as warranted by condition; reports to other providers as needed.
- Reports sentinel events or adverse drug reactions or incidents as warranted.
- Uses final verification before invasive procedures & can verbalize correct process & documents in EHR.
- Reassesses patient in response to changes in condition after intervention as needed & documents in EHR.
- Attend all Care Coordinator training webinars & meetings.
- Provide feedback for the improvement of the Care Coordination program.
- Assist with the identification of “high-risk” patients (the chronically ill & those with special health care needs).
- Work with patients to plan & monitor care; assess patient & family’s unmet health & social needs; develop a care plan with the patient, family & providers (emergency plan, medical summary, & ongoing action plan as appropriate); monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way & facilitate changes as needed; create ongoing processes for patients & families to determine level of care coordination support they desire at any given point in time.
- Serve as the contact-point, advocate & informational resource for patient, family, payers & community resources.
- Facilitate patient access to appropriate medical & specialty providers.
- Educate patient & family about relevant community resources.
- Cultivate & support primary care & subspecialty co-management with timely communication, inquiry, follow-up, & integration of information into the care plan regarding transitions-in-care & referrals.
- Facilitate & attend meetings between patient, family, care team, payers & community resources as needed.
Required Skills/Abilities:
- Demonstrates professional, appropriate, effective & tactful, written, verbal & nonverbal communication skills.
- Demonstrates a positive attitude & respectful, professional customer service.
- Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, & follows HIPAA guidelines & regulations.
- Proactively acts as patient advocate, responding with empathy & respect to resolve patient & family concerns, & recognizes opportunities for improvement to meeting patient concerns.
- Proactively continues to educate self on providing quality care & improving professional skills.
- Effectively communicates both verbal & written.
Education and Experience:
- Minimum Associates degree in nursing, Bachelor’s degree preferred
- Minimum of 2 years relevant work experience required
- Must be licensed as a Registered Nurse in the state of Indiana
Physical Requirements:
- Frequent walking, standing, pushing, pulling, stooping, kneeling, reaching, talking, & use of hands
- Occasionally may need to lift up to 25 lbs