Clinical Care Coord/RN

Northern Light Health•Portland, ME

42d•Onsite

About The Position

The Clinical Care Coordinator designs, implements and participates in care coordination practices that seek to improve patient outcomes and decrease costs while consistently demonstrating effective patient-centered care. The incumbent coordinates and guides the patient navigation process for patients and their families with a cardiac diagnosis or other complex surgical/medical events. The Clinical Care Coordinator collaborates with an interdisciplinary team to ensure high quality care across all delivery sites and serves as a single point of contact for patients, caregivers, referring physicians and the community. The Clinical Care Coordinator works closely with physicians to develop data processes/analysis in order to track patient progress and outcomes. The Coordinator will be responsible for updating and maintaining American College of Cardiology databases, and is responsible for participation in and compliance with all patient safety initiatives and regulations associated to the position. Conducts all job responsibilities according to the Mission and Values of the Hospital. Is fully compliant with HIPAA regulations.

Requirements

BLS Required.
Required Registered Nurse
Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

Responsibilities

Collaborates with physicians and ancillary staff, other services, patients and patient's family to create patient-centered care coordination, manage symptoms, and evaluate patient outcomes.
Meets with patients and patients' family with a new diagnosis of cardiovascular disease or other complex surgical/medical diagnosis to provide anticipatory guidance, education, psychosocial support, answer questions, and facilities appointment scheduling and access to resources during the treatment-planning phase.
Serves as a single point of contact for patient's, patient's family, referring physicians and other members of the integrated, multidisciplinary healthcare team who have questions about the plan of care, need guidance with care coordination and access of additional clinical and/or supportive resources, or questions related to pre and post care.
Responsible for the coordination and delivery of clinical nursing care and services according to current policy and standards of care.
Initiates patient education and follow-up according to the individualized treatment plan, physical and psychosocial needs of the patient in collaboration with the physician.
Collaborates with the clinical and multidisciplinary team to support the navigation process regarding the care of highly complex patients to assure continuity during care path transitions.
Make appropriate referrals to social services, financial counselors, nutrition, home care, and additional community services to support a comprehensive quality care model.
Provides consistent care coordination to patients and families through assessment of actual or potential health needs, health promotion, education, symptom management, counseling and decision support and coordination of care across all care sites.
In collaboration with physician and interdisciplinary care team, coordinates a follow-up plan of care after the initial phase of a patients treatment is complete
Serves as a liaison to the in-patient unit and home care agencies in the communication and coordination of continuous patient care.
Conduct follow-up patient calls post hospital discharge and/or following changes in the patient plan of care to evaluate nutritional needs, education needs, level of understanding, outcomes and reinforce the plan of care.
Assists in the coordination, scheduling and tracking of patient compliance with appointments, screening, diagnostic and follow-up tests and procedures.
Tracks, reviews and monitors follow-up of diagnostic test results, under the direction of the physician. Provides related education, counseling, ongoing review and monitoring regarding diagnostic tests.