Care Coordinator II

KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1•Goldendale, WA

7d•$41 - $59•Onsite

About The Position

Care Coordination and Innovation is a constantly evolving program for KVH and for the state of Washington, which means that the Care Coordination leader must be able to think and work independently, creatively, productively, and in an environment with few established policies and procedures to guide their work. This work will be complex (both broadly conceptual and tedious and detailed), requiring a mature, holistic approach in order to be successful. The Care Coordinator is primarily responsible for coordinating and expediting care for patients attributed to the Accountable Care Organization and Medicaid affiliates; effectively communicating with patients, providers and community support organizations to coordinate and facilitate a comprehensive plan of care for patients; and facilitate a shared goal model within and across settings to achieve coordinated high-quality care that is patient/family centered.

Requirements

Graduate of an accredited school of nursing with a minimum of an Associate’s Degree in Nursing.
Three (3) years of nursing experience providing direct patient care in the acute care, home health, or outpatient physician clinic environment with evidence of strength in areas of leadership, creativity, flexibility, self-direction, organization, problem-solving, communication, and multi-tasking.
Experience using health care IT systems and data.
Experience with community building, health professional education, and/or working with populations enrolled in subsidized health services.
Document management skills to support work plan creation and maintenance, teaching, record keeping and, communication.
Experience teaching others with a variety of learning and retention styles.

Nice To Haves

Bachelor’s degree preferred.
Continuing education and/or specialized training in managed care or outpatient clinic operations preferred.
Ability to obtain certification in Annual Wellness Visits within six months of hire.
Experience creating and continuously improving processes and systems of care, including clinical care delivery and administrative functions supporting such care preferred.

Responsibilities

Coordinates team-based care through effective partnerships with patients, their caregivers, and their providers.
Communicates effectively with primary care providers, hospitals, specialists and post acute care facilities to schedule appointments and identify and fill gaps of care; facilitates access to appropriate primary and specialty providers as well as other care coordination team support specialists (e.g. Podiatry; Wound Care); follows-up to ensure patients follow through with their scheduled appointments; coordinates requests for care and provides timely communication to facilitate progress toward common goals.
Provides a coordinated strategic approach to detect and effectively manage patients with chronic disease.
Establishes an effective tracking system for identified patients.
Coaches patients/families toward successful self-management of chronic disease; assesses patient and family’s unmet health and social needs; provides effective communications to improve health literacy; educates patient on availability of resources such as psycho-social support, treatment resources, family educational resources and financial assistance; monitors patient adherence to plan of care and progress toward goals.
Serves as the point-of-contact, advocate, and informational resource for patient, family, care team, payers, and community resources.
Facilitates and attends meetings between patient, family, care team, payers, and community resources, as needed.
Proactively acts as patient advocate; responds with empathy and respect to resolve patient/family concerns.
Creates processes to effectively track, monitor, and report on participant and provider performance that includes data points such as cost per patient, diagnosis, risk factors, inpatient readmissions, ED visits, preventative care, and social activities.
Provides trending and analysis to improve care and services.
Researches and analyzes alternatives for improving programs and care.
Develops “best practice” recommendations by partnering with outside organizations, examining data and identifying trends.
Promotes healthy behaviors in all populations and provides navigation assistance with community resources.
Organizes community educational events to increase awareness of preventative and wellness services.
Participates in ACO and Medicaid care coordination meetings and training opportunities.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.
Consistently demonstrates KVH values and provides all patients/customers with an excellent service experience.
Performs other related duties as assigned.