Patient Care Coordinator

 

Reports To:

Program Manager

 

OVERVIEW:

 

McCook Clinic has an opening in Nursing for a Patient Care Coordinator position.

 

The Care Manager’s primary responsibility is to manage care for the patients of the primary care practice to promote effective education, self-management support, and timely health care delivery. This will include developing and monitoring care management processes and support primary clinical teams with these efforts. It will also include identifying the high acuity patient population and working to ensure care coordination for this patient population. The position may involve some patient triage.

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The Care Manager behaves in a professional manner, and consistently demonstrates and promotes the values of McCook Clinic’s vision. The Care Manager will work with the Program Manager and Medical Staff of the practice to develop this

position to best serve the needs of the patient panel and the primary care teams. The Registered Nurse or Licensed Practical Nurse will demonstrate performance consistent with professional standards of practice, care, and the Nurse Practice Act.

 

RESPONSIBILITIES:

Care Management

• Work with all clinical teams as a resource on care management of all patients of the practice, this would include the following:

  • Optimizes care coordination with hospital, emergency room, consulting physicians, community resources as necessary.

  • Develops a workflow to ensure smooth transition of care for patients treated in a facility (inpatient or emergency room), by a specialty physician, or by another health care provider.

  • Involving the patients in activities to improve their health (patient engagement).

  • Educating the patient about self-management tasks they can undertake to gain greater control of their health status.

  • Manages patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner.

  • Provides leadership for the patient care teams.

  • Actively manages assigned panel of chronic care patients (high acuity).

  • Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.

  • Develops a relationship with patients as an integral member of team.

  • Provides follow up contact with patients as indicated to ensure compliance with recommendations – medications, lab/X-Ray, specialists visits, primary care visits, dieticians, CDE, etc.

• Responsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls.

• Anticipates the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient

• Promotes patient self-management and empowers patients/families to achieve

       maximum levels of wellness and independence.

• Responsible for working with patient and patient’s care team to coordinate change readiness, needs assessment and develop an individualized treatment care plan.

• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.

• Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.

• Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.

• Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees as applicable.

• Promotes collaboration of teamwork; able to work with peers in a team situation.

• Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most

• Works with IT staff member(s) or department to coordinate the following:

  • EMR documentation to ensure use of searchable fields

  • Efficient consult request communication

  • Consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals

• Performs any additional tasks requested by Practice Administrator, Program Manager, or Physicians.

 

SKILLS:

• Knowledge of medical practice and care of patients

• Knowledge of examinations, diagnostic and treatment procedures

• Knowledge of medical equipment and instruments

• Knowledge of common safety hazards

• Skills in developing and maintaining clinical quality assurance

• Ability to use good judgment and critical thinking skills; ability to identify and resolve problems

• Ability to interpret, adapt, and apply guidelines and protocols

• Ability to maintain medical records

• Ability to establish and maintain effective working relationships with patients, families, medical staff, and co-workers

• Ability to work independently, while collaborating with other team members

• Ability to self-motivate, prioritize, and be willing to invest in a change process to improve efficiencies

• Excellent written, verbal and listening communications skills

• Proficient computer skills – data entry, retrieval and report generation

• Ability to work with a diverse patient/family population

 

QUALIFICATIONS:

• State of Nebraska Registered Nursing License or Licensed Practical Nurse

• Preferred minimum of three years of experience as a licensed nurse, preferably five years of experience including home care clinical experience

• Experience in provision of primary care with this population is highly desirable

• Supports practice mission and goals