Integrated Care Coordinator Nurse

Seven Counties Services•Louisville, KY

7d•Onsite

About The Position

Provides first point of clinic contact for all new clients, explaining services available and focusing on client engagement to access services. Completes health screenings, nursing assessments, and triages healthcare needs for new and ongoing clients. Participates in team meetings to develop a plan of care to address client needs. Assists clients in navigating the healthcare environment to ensure access to appropriate care and advocates on their behalf with healthcare providers and managed care organizations to ensure timely care. Assists with coordination and access to services that address social determinants of healthcare outcomes, including transportation to healthcare appointments, identifying other needs, assisting in obtaining access to housing, and assisting with access to other community resources. Develops a knowledge base of other healthcare providers in the service area and collaborates as needed. Documents tracking for appointments, medication, and other healthcare needs for assigned clients. Provides education and support for wellness activities such as healthy eating, physical activity, and healthy behaviors. Assists clients who have recently discharged from inpatient treatment, incarceration, residential care, and/or Emergency Department visits to ensure a transition to outpatient care using evidence-based transitional/navigation services to prevent readmissions. Provides caring contacts to clients estimated to be at high risk for suicide to ensure continuity of care. Collaborates with client, family/significant others to develop support networks. The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description.

Requirements

Licensed Practical Nurse preferred with current active license to practice in Kentucky.
Medical Assistant may be considered based on academic preparation and relevant experience.
Three years of nursing experience in a hospital, physician office, or behavioral care clinic.
Experience in community setting or integrated care environment.
Reliable transportation for frequent travel.

Responsibilities

Provides first point of clinic contact for all new clients.
Explains services available and focus on engagement of client to access services.
Completes health screenings, nursing assessments and triage healthcare needs for new and ongoing clients.
Participates in team meeting to develop a plan of care to address client needs.
Assists clients in navigating the healthcare environment to ensure access to appropriate care.
Advocates on client’s behalf with healthcare providers and managed care organizations to ensure timely care.
Assists with coordination/access to services that address social determinants of healthcare outcomes.
Provides transportation to healthcare appointments, when needed.
Identifies other needs, when necessary, that ensure access to healthcare.
Assists in obtaining access to housing (search for housing, applications, financial assistance, communication with landlord), as necessary, when housing status destabilizes health status and presents a barrier to receiving appropriate healthcare.
Assists with access to other community resources e.g., public assistance and financial benefits.
Develops knowledge base of other healthcare providers in the service area and collaborate, as needed.
Documents tracking for appointments, medication, and other healthcare needs for assigned clients, as needed.
Provides education and support wellness activities such as such as healthy eating, physical activity, and healthy behaviors.
Assists clients who have recently discharged from inpatient treatment, incarceration, residential care, and/or Emergency Department visits to ensure a transition to outpatient care using evidence-based transitional/navigation services to prevent readmissions.
Provides caring contacts to clients estimated to be at high risk for suicide to ensure continuity of care.
Collaborates with client, family/significant others to develop support networks.