Assistant Clinical Care Coordinator (Primary Care Clinic)

Fort Defiance Indian Hospital Board, Inc.•Fort Defiance Agency, AZ

7d•$29 - $36

About The Position

The Assistant Clinical Care Coordinator supports care coordination for patients with complex and chronic health needs in a primary care clinic. The role develops, implements, monitors, and updates comprehensive care plans with patients, families, and care teams; coordinates with clinics, inpatient services, mental health providers, and community agencies; and facilitates meetings and communication among those involved in patient care. The coordinator educates and supports patients and families, helps them access medical and other services, maintains chronic disease registry information, and serves as a resource and advocate for families, community partners, payers, and FDIHB staff. The position also contributes to referral processes, policies and procedures, quality improvement, patient screening, community education, and educational materials. It attends to specific clinical needs of empaneled complex patients in clinic or inpatient settings in collaboration with primary care providers and clinical nurses, and supports compliance with CMS standards and required training. Applicants must have a valid, unrestricted, insurable driver's license. A resume and references are required.

Requirements

Two years of Nursing Assistant, Medical Assistant, or healthcare-related experience in a clinical, medical/surgical, critical care, or outpatient setting.
Associate of Science degree in Nursing, Social Work, Human Services, or a related field from an accredited program.
Valid American Heart Association Basic Life Support (BLS) certification and ability to maintain certification.
Valid and unrestricted license in any U.S. state or territory.
Valid, unrestricted, insurable driver's license.
Resume and references are required.
Submit degree, transcripts, license, and certifications by email as instructed.

Responsibilities

Develop, implement, evaluate, and continually update comprehensive care plans with patients, families, and care teams.
Coordinate care among families, clinics, inpatient services, mental health providers, and other involved agencies and services.
Facilitate team conferences and meetings, and attend community meetings with families as needed.
Support subspecialty co-management through timely communication, inquiry, follow-up, and integration of information into care plans.
Educate, counsel, and support patients, provide appropriate anticipatory guidance, and intervene or facilitate referrals during crises.
Build care relationships and patient-specific skills among families and care teams, support families’ primary caregiving role, and facilitate access to medical, psychological, developmental, educational, social, and financial services.
Help identify patients with chronic care needs, maintain the chronic disease registry, and use it to plan and monitor care while applying appropriate inclusion and exclusion criteria and case-finding strategies.
Understand and catalog eligibility requirements, referral processes, and funding details for public and private services and develop procedures that facilitate access based on patient needs.
Serve as a point of contact, advocate, and information resource for families, community partners, and payers, including maintaining a close working relationship with the FDIHB Purchase Referred Care department.
Serve as a consultant and resource to FDIHB staff on patient-care issues.
Assist in developing and maintaining policies and procedures for care coordination of complex chronic patients and screening for complex chronic medical issues.
Assist in developing formal referral forms, policies, and procedures for accessing services.
Participate in quality improvement by measuring quality and identifying, testing, refining, and implementing practice improvements.
Maintain professional growth through seminars, workshops, independent study, and professional affiliations.
Attend to empaneled complex patients’ clinical needs in the clinic or inpatient unit as needed, collaborating with primary care providers and clinical nurses.
Provide community outreach and education about chronic care patients, their needs, and the Chronic Care Model.
Assist in developing and maintaining educational materials and provide instruction or other learning opportunities for target audiences.
Apply age-specific, developmentally appropriate, and culturally appropriate education and learning principles.
Respond to community queries about chronic diseases and related issues.
Complete annual CMS-required training by applicable due dates and support compliance with established CMS standards.
Perform other duties as assigned.