Coordinator, Patient Care - Metro Nashville Public Schools Onsite Clinics

Vanderbilt University Medical Center•Berry Hill, TN

17h•Onsite

About The Position

Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system. The MNPS Employee & Family Health Care Centers are operated by Vanderbilt Health and staffed by an interdisciplinary team that works together to provide compassionate, whole-person care and health guidance to MNPS and Metro Government employees and their family members. There are five locations across Davidson County. Our board-certified nurse practitioners and physician assistants provide full-spectrum primary care — performing exams, diagnosing and managing both acute and chronic conditions, and prescribing medications when needed. This role supports Whole Person Care initiatives and Lifestyle Medicine programs for MNPS employees and members that focus on preventing and treating chronic disease through lifestyle interventions.

Requirements

LIC-Registered Nurse - Licensure-Others
Relevant Work Experience
5 years
Bachelor's

Nice To Haves

National Board Certified Health and Wellness Coach (NBHWC)
American College of Lifestyle Medicine Certification (DipACLM)
Experience with or strong interest in Lifestyle Medicine, population health, employer/employee health and wellness
Program / project management experience
Complex case management experience

Responsibilities

Plan, support and facilitate group medical visits (GMVs)
Assist with Lifestyle Medicine program design
Lead the MNPS Patient Advisory Group
Support Whole Person Care initiatives
Collaborate with providers and staff across clinic locations
Work directly with the MNPS Medical Director on programs, research, and initiatives
Work closely with the Whole Person Care Navigation team
Data collection (Excel, Epic slicer dicer. REDCap)
Coordinates the evaluation process of the defined patient population.
May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc.
Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence