Chronic Care Coordinator

Kalihi Palama Health Center•Honolulu, HI

2d•$38 - $45•Onsite

About The Position

The Chronic Care Coordinator is a vital member of the Patient Centered Medical Home (PCMH) team, contributing to patient-centered health care. This role involves developing individualized, person-centered care plans for patients with complex and chronic illnesses, adhering to KPHC's clinical care coordination model and evidence-based practices. The position also engages in healthcare innovation, leading projects and activities to enhance the quality of patient care and improve health outcomes.

Requirements

Knowledge and skill in the delivery of community healthcare.
Knowledge of community resources, how to access them, and awareness of government assistance programs.
Ability to assess and plan in a multi-cultural context.
Professionalism, sound clinical skills, and emotional stability.
Ability to communicate comfortably with multi-ethnic populations.
Flexibility in program development and evolution.
Strong organizational skills.
Database creation and maintenance desirable.
Intermediate ability to use MS Windows including Word, Excel, PowerPoint and Access.
Associate Degree in Nursing required.
An active Hawaii State RN license required.
2 years general experience providing patient care in a community or hospital setting preferred.
1 year case management experience or experience providing health education and outreach activities preferred.

Nice To Haves

Bachelor of Science in Nursing preferred.

Responsibilities

Leads the PCMH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
Assesses patient needs and facilitates referrals and care coordination with internal and external stakeholders.
Provides patient education and sets SMART goals.
Establishes person-centered care plans in collaboration with patients and providers, following NCQA-PCMH guidelines.
Identifies and ensures closure of care gaps in alignment with NCQA-PCMH, HEDIS, and health plan requirements.
Executes interventions to reduce inappropriate ER visits or hospital length of stay, improving care and reducing costs.
Provides staff training on care coordination and chronic diseases.
Organizes and coordinates chronic disease patient classes (e.g., diabetes, asthma, CKD, memory clinic).
Works with internal and external teams to achieve PCMH goals and objectives.
Implements policies, procedures, and processes developed by the PCMH team.
Ensures KPHC's PCMH team implements changes based on the chronic care model, KPHC, and PCMH standards and guidelines.
Provides oversight to support staff assisting in care coordination activities.
Prepares monthly reports and updates for the Director of Clinical Operations.
Assists the Director of Clinical Operations in quality improvement and data validation activities.
Serves as a liaison for care coordination to insurance companies and other organizations.
Explores community resources and establishes partnerships to facilitate improvement.
Supports multi-cultural projects to enhance patient care delivery.
Performs direct nursing care, including triage, nurse advice, floor duties, and covering other departments as necessary.
Supports and supervises support staff.
Maintains awareness of clinic and community services to meet client needs.
Maintains awareness of legal and legislative issues impacting service availability.
Participates in clinic quality improvement activities.
Works with the adult medicine care team to assess and modify quality improvement strategies.
Maintains client confidentiality per clinic protocol.
Develops and implements forms for data collection, tracking, and documentation of activities.
Works with the adult medicine team to determine effective communication strategies.
Works closely with other clinic staff on chronic disease-related projects involving clients.
Performs other related duties as assigned.
Observes safety and security procedures, determines appropriate actions beyond guidelines, reports potentially unsafe conditions, and uses equipment and materials properly.