Clinical Care Coordinator (Primary Care Clinic)

FDIHB•Fort Defiance, AZ

11h•Onsite

About The Position

The Clinical Care Coordinator will develop and implement comprehensive care plans for patients, coordinating with families, healthcare teams, and external agencies. This role involves assessing patient health status, managing chronic care needs, and facilitating access to various services. The coordinator will also serve as a consultant to staff, contribute to quality improvement initiatives, and provide direct patient care as needed. Additionally, the position requires developing and maintaining policies and procedures related to chronic disease management and care coordination, as well as providing community outreach and education.

Requirements

Two (2) 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 and unrestricted Registered Nurse license in any U.S. State or Territory.
Valid American Heart Association certification in Basic Life Support (BLS) and maintain certification.
Applicant must have a valid, unrestricted insurable driver’s license.
Resume and references are required.

Responsibilities

Develops and implements comprehensive care plans with patient, family, and team, and continually monitors/updates these plans based on patient/family needs.
Coordinates inter-organizationally with family, Ambulatory Clinics, inpatient services, and involved services and agencies; facilitates "wrap around" meetings or team conferences and attends community meetings with family as necessary.
Observes and assesses health status of patients by physical assessment and examination, interviewing patient and family member, and reviewing patient's health history.
Cultivates and supports assigned care & subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan.
Educates, counsels, supports and provides patient appropriate anticipatory guidance.
In a crisis, intervenes or facilitate referrals appropriately.
Builds care relationships and patient-specific skills among family and team; supports the primary care-giving role of the family.
Facilitates patient/family access to available medical, psychological, developmental, educational, social, and financial services and supports.
Assists with or promotes the identification of patients with chronic care needs; adds to and maintains chronic disease registry and uses registry to plan and monitor care.
Understands eligibility requirements, referral processes, and funding details for available public and private sector services and programs; catalogs these details and formulates procedures that facilitate access to these services.
Serves as the point-of-contact, advocate, and informational resource for family and community partners/payers, including having a close working relationship with the FDIHB Purchase Referred Care Department.
Serves as a consultant and resource person to FDIHB staff on issues regarding patients and their care.
Develops and maintains policies and procedures related to the care and care coordination of complex patients with chronic diseases.
Develops and maintains policies and procedures related to the screening of patients for the presence of complex, chronic medical issues.
Develops formal referral forms, policies, and procedures that relate to accessing these services and supports.
Serves as a quality improvement team member; helps to measure quality and to identify, test, refine and implement practice improvements.
Maintains professional growth and development through seminars, workshops, independent study, and professional affiliations.
Attends to specific clinical needs of empaneled complex patients on an as needed basis in the clinic and/or on the inpatient unit.
Provides skilled and comprehensive nursing care to patients as needed.
Offers outreach and education to the community related to chronic care patients, their issues, their needs, and details regarding the function of the Chronic Care Model.
Develops and maintains related educational materials and provides instruction or other learning opportunities to meet the needs of the target audience.
Utilizes theories and principles of education/learning to foster the educational development of the target audience.
Fields queries from the community regarding patients with chronic care diseases and issues related to this patient population.
Completes all yearly Center for Medicare and Medicaid Services (CMS) required training by the indicated dues date.
Assists, promotes, and supports compliance with established CMS standards.
Performs other duties as assigned.