Clinical Care Coordinator (Surgical Clinic)

FDIHB•Fort Defiance, AZ

23h

About The Position

The Clinical Care Coordinator develops and implements comprehensive care plans with patients, families, and care teams, and continually evaluates and updates plans according to patient and family needs, strengths, and available resources. The role coordinates care across family members, ambulatory clinics, inpatient services, and external services and agencies, and serves as a point of contact, advocate, and information resource for families and community partners. The coordinator assesses patient health through examination, interviews, and health-history review; supports subspecialty co-management; provides education and anticipatory guidance; and intervenes or facilitates referrals during crises. The role helps families access medical, psychological, developmental, educational, social, and financial services, and supports chronic-care identification, registry maintenance, and care monitoring. It also develops and maintains screening, referral, and care-coordination policies and procedures, contributes to quality improvement, provides clinical nursing care to complex patients as needed, and offers community education and outreach about chronic care. The position requires an Associate of Science degree in Nursing from an accredited nursing program, two years of Registered Nurse experience in a clinical, medical/surgical, acute, and/or critical care setting, an unrestricted RN license in a U.S. state or territory, and current American Heart Association Basic Life Support certification. A valid, unrestricted insurable driver’s license is also required. The role must complete annual CMS-required training and support compliance with CMS standards. Navajo/Indian employment preference applies.

Requirements

Two years of Registered Nurse experience in a clinical, medical/surgical, acute, and/or critical care setting.
Associate of Science degree in Nursing from an accredited nursing program.
Valid, unrestricted Registered Nurse license in any U.S. state or territory.
Valid American Heart Association Basic Life Support (BLS) certification and ability to maintain certification.
Valid, unrestricted insurable driver’s license.
Submit degree, transcripts, license, and certifications by email as instructed in the posting.

Responsibilities

Develop, implement, evaluate, and continually update comprehensive care plans with patients, families, and care teams.
Coordinate care among families, ambulatory clinics, inpatient services, and involved organizations and agencies; facilitate team conferences and attend community meetings as needed.
Assess patients’ health status through physical assessment and examination, interviews, and review of health histories.
Support subspecialty co-management through communication, inquiry, follow-up, and integration of information into care plans.
Educate, counsel, and support patients and provide appropriate anticipatory guidance; intervene or facilitate referrals during crises.
Build care relationships and patient-specific skills among families and care teams, supporting the family’s primary caregiving role.
Facilitate patient and family access to medical, psychological, developmental, educational, social, and financial services and supports.
Identify patients with chronic-care needs; maintain the chronic disease registry and use it to plan and monitor care, applying appropriate case-finding and eligibility criteria.
Catalog service and program eligibility, referral processes, and funding details, and develop procedures that facilitate access according to patient needs.
Serve as point of contact, advocate, and information resource for families and community partners and payers, including maintaining a close working relationship with the FDIHB Purchase Referred Care Department.
Consult with and serve as a resource for FDIHB staff on patient-care issues.
Develop and maintain policies and procedures for complex chronic-care coordination and screening, and develop referral forms and procedures for accessing services and supports.
Participate in quality improvement by measuring quality and helping identify, test, refine, and implement practice improvements.
Maintain professional growth through seminars, workshops, independent study, and professional affiliations.
Address empaneled complex patients’ clinical needs in clinic or inpatient settings as needed, collaborating with primary care providers and clinical nurses and providing skilled nursing care as needed.
Provide community outreach and education about chronic-care patients, their needs, and the Chronic Care Model; develop educational materials and learning opportunities appropriate to the audience.
Respond to community inquiries about chronic diseases and this patient population.
Complete required annual CMS training and assist with compliance with established CMS standards.
Perform other duties as assigned.