About The Position

The SFAN Care Coordinator is a professional member of the health care team who assumes advocacy and accountability and works in collaboration and continuous partnership with chronically ill or high-risk patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to provide a continuity of the single standard of care.

Requirements

  • Bachelor's degree in related field is required.
  • Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines.
  • Ability to communicate effectively in both oral and written form.
  • Ability to handle difficult and stressful situations with professional composure.
  • Ability to understand and follow instructions.
  • Ability to exercise sound and independent judgment.
  • Knowledge and skill in use of job appropriate technology and software applications.
  • Ability to understand, respects and accommodates patient's preferences and needs with regards to their individual beliefs, customs and practices.
  • Must have ability to clearly, accurately and effectively provide information to doctors, other nurses, patients, and family members.
  • Must have ability to show compassion, patience and maintain non-judgmental approach to patients, their families as well as other employees and customers.
  • Must have knowledge, skill and ability to fully and accurately complete all required unit competencies, as indicated in the unit competency check-list.
  • Valid license or certification is required as needed, based on the job or specialty.

Nice To Haves

  • Case Management highly preferred

Responsibilities

  • Conducts assessment of client's medical, financial and psychosocial needs.
  • Develops and implements care plans based on identified medical, financial and psychosocial needs.
  • Monitors clients' health and compliance with proposed medical treatment.
  • Updates care plans based on needs.
  • Promotes medication and treatment adherence by providing education, referrals and resources for care and treatment.
  • Coordinates patient primary, specialty care and social service care through continuous monitoring of specific diagnosis and procedures.
  • Maintains professional relationships with community service providers as a liaison to secure available resources in a client-centered and compassionate manner.
  • Maintains knowledge of Federal, State and local eligibility requirements for Ryan White and General Revenue Services.
  • Coordinates eligibility and enrollment for housing, shelter and residential treatment programs.
  • Prepares and reviews reports in a timely manner.
  • Submits monthly billing documentation and maintains accurate client case record file.
  • Maintains contact with clients based on care and treatment plans.
  • Knowledgeable and proficient in specialized systems, as required by grant funders.
  • Performs independently in coordinating and tracking patient care, and providing care planning for patients.
  • Provides discharge /educational instruction for patients/families related to HIV Care and treatment.
  • The SFAN CC participates in the development of the care plan for patient care, according to patient's medical and social needs. In collaboration with the multidisciplinary health care team, the SFAN CC utilizes clinical pathways in support of the provision of care.
  • The SFAN CC collaborates with other health care team members and with external payer sources in the delivery and coordination of care.
  • Also responsible for tracking of quality measures related to care coordination efforts.
  • Screens and assesses patient records, as assigned, using specific criteria and critical judgment, in order to identify needs and refers clients to services.
  • Reviews pertinent documentation, interprets clinical data; identifies variations in care and or utilization based on knowledge of disease processes and appropriate treatment modalities, relevant data.
  • Participates in hospital-wide quality improvement activities (fire drills).
  • Maintains knowledge of JCAHO standards and assists with preparation for JCAHO survey and visit as needed.
  • Participates in community seminars and continuing education programs in order to enhance own knowledge base and to exchange appropriate information with peers.
  • Demonstrates effective interpersonal communication skills through the development and maintenance of productive working relationships with medical staff, nursing, ancillary departments, administrative staff and peers.
  • Follows and performs all related unit specific policies and procedures, as detailed on the unit specific competency check-list.
  • Utilizes job and unit specific equipment as required.
  • Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).
  • Performs all other related job duties as assigned.
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