Clinic Care Coordinator RN
Full time, Dayshift
Monday - Friday
The Clinic Care Coordinator RN coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient-and family-centered.
ESSENTIAL JOB FUNCTIONS:
- Provides a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
- Implements an effective internal tracking system for identified patients.
- Coaches patients/families toward successful self-management of their chronic disease.
- Utilizes tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
- Assesses patient and family’s unmet health and social needs.
- Provides effective communications to improve health literacy.
- Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
- Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
- Promotes healthy behaviors in all populations and ensure navigation assistance with community resources.
- Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).
- Cultivates and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
- Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
- Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.
- Develops systems to prevent errors (e.g., effective medication reconciliation and shared medical records).
- Facilitates and attend meetings between patient, families, care team, payers, and community resources, as needed.
- Attends and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other NRACO Care Coordinators and Coach).
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home.
- Conducts audits and chart review as per the PCMH model.
- Supports subordinates as requested.
- Demonstrates knowledge of infection control standards and adheres to the guidelines for handwashing, standard precautions, and bloodborne pathogens as required by DOSH.
- Maintains confidentiality of all hospital and patient information at all times as observed by peers and management.
- Demonstrates awareness of safe work habits and maintains a safe working environment by adhering to department and hospital policies, including but not limited to, zero lift, SDS, body mechanics and ergonomics.
- Demonstrates compliance to all Human Resources policies, including but not limited to, attendance, dress code, smoking, and name badges.
- Attends department meetings and participates in mandatory education.
- Conducts self in a professional manner and is pleasant, respectful, and courteous in all interactions with patients, families, staff, and other visitors to the hospital.
- Promotes effective working relationships and works cohesively with employees both within and outside of the department.
- Understands and demonstrates the mandatory reporting process for abuse or neglect as required by the Department of Social and Health Services.
- Must have current Registered Nurse License from the State of Washington and active CPR certification.
- Basic computer skills are required.
- Previous experience in caring for chronic disease patients preferred.
- 3-5 years’ experience in clinical or community health settings preferred.
- Previous Care Coordination, Case Management or Home Health experience preferred.
- Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
- Proficient in communication technologies (email, cell phone, etc.).
- Effective organizational skills and demonstrates ability to maintain accurate notes and records.
- Previous experience with health IT systems and data reports preferred.
- Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
- Bilingual preferred. Must be able to speak, read and write, and follow oral/written instructions in English.
- Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.
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