CLINICAL CARE COORDINATOR (SURGICAL CLINIC)

Fort Defiance Indian Hospital Board, Inc.•Fort Defiance Agency, AZ

1d•$48 - $62

About The Position

The Clinical Care Coordinator develops, implements, and continually updates comprehensive care plans with patients, families, and care teams. The plans may include an emergency plan, medical summary, and action plan, and are adjusted according to patient and family needs, strengths, and assets. The coordinator assesses patients through physical assessment and examination, interviews with patients and family members, and review of health histories. The role coordinates care among families, ambulatory clinics, inpatient services, and other involved services and agencies, and facilitates team conferences and community meetings as needed. The coordinator supports care and subspecialty co-management through timely communication and follow-up; educates and counsels patients and families; provides anticipatory guidance; and intervenes or facilitates referrals during crises. The role helps families and care teams build care relationships and patient-specific skills, supports family caregiving, and facilitates access to medical, psychological, developmental, educational, social, and financial services. It also identifies patients with chronic care needs, maintains and uses a chronic disease registry, and develops procedures that help patients access relevant services and programs. Additional duties include serving as a contact, advocate, and resource for families, community partners, and payers; consulting with FDIHB staff on patient care; developing policies, procedures, and referral forms; and contributing to quality improvement. The coordinator provides nursing care to empaneled complex patients as needed in clinic or inpatient settings, collaborating closely with primary care providers and clinical nurses. The role also provides community outreach and education, develops educational materials, completes required CMS training, and supports compliance with CMS standards. Other duties may be assigned.

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.
Resume and references are required.
Applicants must email degree, transcripts, license, and certifications to [email protected].

Responsibilities

Develop, implement, evaluate, and update comprehensive care plans with patients, families, and care teams.
Coordinate care among families, ambulatory clinics, inpatient services, and involved services and agencies; facilitate team conferences and community meetings as needed.
Assess patients’ health through physical assessment and examination, patient and family interviews, and review of health histories.
Support care and subspecialty co-management through timely communication, inquiry, follow-up, and integration of information into care plans.
Educate, counsel, and support patients and families; provide anticipatory guidance and facilitate referrals or interventions during crises.
Build care relationships and patient-specific skills among families and care teams, support family caregiving, and facilitate access to services and supports.
Identify patients with chronic care needs, maintain a chronic disease registry, and use it to plan and monitor care while applying appropriate inclusion and exclusion criteria.
Understand and document eligibility requirements, referral processes, and funding details for public and private services, and develop procedures to facilitate access.
Serve as a point of contact, advocate, and informational resource for families, community partners, and payers, including maintaining a close working relationship with the FDIHB Purchase Referred Care Department.
Serve as a consultant and resource to FDIHB staff on patient care issues.
Develop and maintain policies and procedures for care coordination of complex patients with chronic diseases and screening for complex chronic medical issues.
Develop formal referral forms, policies, and procedures for accessing services and supports.
Participate in quality improvement by measuring quality and identifying, testing, refining, and implementing practice improvements.
Maintain professional growth through seminars, workshops, independent study, and professional affiliations.
Attend to clinical needs of empaneled complex patients in clinic or inpatient settings as needed, collaborating with primary care providers and clinical nurses.
Provide skilled and comprehensive nursing care to patients as needed.
Provide community outreach and education regarding chronic care patients, their needs, and the Chronic Care Model.
Develop educational materials and provide instruction or learning opportunities appropriate to the target audience.
Use age-specific, developmentally appropriate, and culturally appropriate education and learning principles.
Respond to community queries regarding chronic care diseases and related issues.
Complete yearly CMS-required training by the indicated due date and support compliance with established CMS standards.
Perform other duties as assigned.