CLINICAL CARE COORDINATOR

NAVAJO HEALTH FOUNDATION - SAGE MEMORIAL HOSPITAL, INC.•Ganado, AZ

About The Position

Under the general supervision of the RN Supervisor of the Outpatient Clinic, the clinical care coordinator accomplishes the Division of Nursing’s strategic objectives of care coordination within Sage Memorial Hospital (SMH) Person Centered Medical Home (PCMH) model and telehealth services through planning, managing, and the deliberate organization of patient care activities between the patient and the healthcare team. The clinical care coordinator will be responsible for promoting and practicing interprofessional collaboration and teamwork, evidence-based care delivery, patient and/or care giver activation and empowerment, and utilization of quality and safety standards. Goals for the care coordinator include but are not limited to improved patient outcomes, optimal patient/provider interactive experience, and cost effectiveness. Incumbent will uphold SMH’s vision, mission, value statements and maintains confidentiality of all privileged information at all times. This list of duties and responsibilities is illustrative only of the task performed by this Position and is not all-inclusive.

Requirements

Bachelor’s Degree in Nursing from an accredited college of nursing in any of the fifty states required, with care coordination experience or case management.
Two (2) years of clinical nursing experience in outpatient, ambulatory care, or PCMH settings or two years’ experience as a nursing supervisor.
Valid and unrestricted nursing license from the State of Arizona or compact licensing state.
Valid American Heart Association Healthcare Providers BLS certification required.
Must be able to successfully pass the Employee Health Program requirements and background investigation.

Nice To Haves

Master’s degree in Nursing from an accredited college of nursing in any of the fifty states preferred.

Responsibilities

Facilitates appropriate, timely, and beneficial delivery of health care services.
Performs ongoing chart reviews for upcoming appointments of PCMH panels and telehealth clinics.
Tracks outstanding tests and results, including monitoring consult results for upcoming appointments.
Conducts post-discharge phone calls as follow-up for identified high-risk patients of PCMH and telehealth clinics.
In collaboration with PCMH teams, will assist in scheduling follow up appointments for patients after discharge to close the continuity of care loop.
Assist in coordination of care between hospitals.
Manages outpatient referrals for the PCMH teams and telehealth clinics.
Develops and maintains internal patient care database for continuous tracking and follow up of continuity of care for active management of patients assigned.
Collaborates proactively with all interdisciplinary team members and with a customer focus to facilitate and maximize patient health care outcomes.
Coordinates multi-disciplinary patient care conferences for high risk or complex customers as needed.
Advocates for the patient/family at the service delivery level and at the policy-making level fostering the patient/family decision making, independence, and growth and development.
Utilizes best practice models to identify, incorporate, or develop best practices for panel management.
Responsible for transition management for patients in PCMH and telehealth clinics by providing ongoing support of patients and their families over time as they navigate care and relationships among more than one provider and/or more than on health care setting and/or more than one health service.
Demonstrate knowledge, skills, and attitudes requisite to the RN-Care Coordination and Transition Management (CCTM) dimensions.
Practice across the care continuum in a variety of settings, such as acute, subacute, and Patient Centered Medical Home settings, including telehealth service environments.
Apply critical and analytical reasoning and astute clinical judgment to expedite appropriate health care and treatment given that patients and/or populations of present with complex problems and/or life-threatening conditions.
Provide CCTM services throughout lifespan for individuals, families, caregivers, groups, populations, and communities.
Interact with patients, healthcare providers, and community resource agencies during face-to-face encounters or through various types of technological communication methods to assess and triage patient issues, provide nursing consultation, perform follow-up and surveillance of status and outcomes, and disseminate pertinent information to all members of the interprofessional CCTM team.
Collect subjective and objective information pertaining to health status from the patient, caregivers, health records, interprofessional members, and any relevant sources to coordinate care.
Utilizes evidence-based materials related to coordination of care and health transitions to facilitate identification of appropriate interventions for improvement and maintenance of health.
Utilize a holistic, patient-centered, evidence-based approach to attaining expected outcomes.
Develop a goal-oriented plan for patients seeking care for health promotion, health maintenance, or health-related situational problems.
Utilize available technology such as electronic health records (EHRs) as well as health plans, and organizational, state, and/or regulatory electronic communication formats and databases to attain expected outcomes.
Utilizes campus software packages and applications for ordering, scheduling, and tracking patient care.
Demonstrates accountability across the care settings in maintaining continuity of care.
Manage high-risk individuals and/or populations with the aim of preventing or delaying adverse outcomes.
Deliver nursing care that reflects the cultural, spiritual, intellectual, educational, and psychosocial differences among patients, families, or communities, and that preserves patient autonomy, dignity, and rights.
Maintain professional and technical knowledge through research studies, attending seminars, educational workshops, classes, and conferences, reviewing professional publications, establishing networks, and participating in professional associations or societies.
Completes all SMH mandatory trainings annually.
Perform as a resource agent for patients, families, staff, and outside entities.
Identify and coordinate continuing care needs for potential home care recipients through assessment and interdisciplinary care rounds.
Meet hospital policies and procedures.
Maintain compliance with applicable laws, regulations, and ordinances including The Arizona Department of Health Division of Licensing Services (AzDH), Centers for Medicare/Medicaid Services (CMS), and The Joint Commission.
Active participation in quality improvement initiatives, and performance improvement assignments.
Performs other duties as assigned.