CLINICAL CARE COORDINATOR

Position Summary:
Under the general supervision of the RN Supervisor of the Outpatient Clinic, the clinical care coordinator accomplishes the Division of Nursing’s strategic objectives of care coordination within Sage Memorial Hospital (SMH) Person Centered Medical Home (PCMH) model and telehealth services through planning, managing, and the deliberate organization of patient care activities between the patient and the healthcare team. The clinical care coordinator will be responsible for promoting and practicing interprofessional collaboration and teamwork, evidence-based care delivery, patient and/or care giver activation and empowerment, and utilization of quality and safety standards. Goals for the care coordinator include but are not limited to improved patient outcomes, optimal patient/provider interactive experience, and cost effectiveness. Incumbent will uphold SMH’s vision, mission, value statements and maintains confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the task performed by this Position and is not all-inclusive.
 

Essential Duties & Responsibilities:

• Facilitates appropriate, timely, and beneficial delivery of health care services.
• Performs ongoing chart reviews for upcoming appointments of PCMH panels and telehealth clinics.
• Tracks outstanding tests and results, including monitoring consult results for upcoming appointments.
• Conducts post-discharge phone calls as follow-up for identified high-risk patients of PCMH and telehealth clinics.
• In collaboration with PCMH teams, will assist in scheduling follow up appointments for patients after discharge to close the continuity of care loop.
• Assist in coordination of care between hospitals.
• Manages outpatient referrals for the PCMH teams and telehealth clinics.
• Develops and maintains internal patient care database for continuous tracking and follow up of continuity of care for active management of patients assigned.
• Collaborates proactively with all interdisciplinary team members and with a customer focus to facilitate and maximize patient health care outcomes.
• Coordinates multi-disciplinary patient care conferences for high risk or complex customers as needed.
• Advocates for the patient/family at the service delivery level and at the policy-making level fostering the patient/family decision making, independence, and growth and development.
• Utilizes best practice models to identify, incorporate, or develop best practices for panel management.
• Responsible for transition management for patients in PCMH and telehealth clinics by providing ongoing support of patients and their families over time as they navigate care and relationships among more than one provider and/or more than on health care setting and/or more than one health service.
• Demonstrate knowledge, skills, and attitudes requisite to the RN-Care Coordination and Transition Management (CCTM) dimensions.
• Practice across the care continuum in a variety of settings, such as acute, subacute, and Patient Centered Medical Home settings, including telehealth service environments.
• Apply critical and analytical reasoning and astute clinical judgment to expedite appropriate health care and treatment given that patients and/or populations of present with complex problems and/or life-threatening conditions.
• Provide CCTM services throughout lifespan for individuals, families, caregivers, groups, populations, and communities.
• Interact with patients, healthcare providers, and community resource agencies during face-to-face encounters or through various types of technological communication methods to assess and triage patient issues, provide nursing consultation, perform follow-up and surveillance of status and outcomes, and disseminate pertinent information to all members of the interprofessional CCTM team.
• Collect subjective and objective information pertaining to health status from the patient, caregivers, health records, interprofessional members, and any relevant sources to coordinate care.
• Utilizes evidence-based materials related to coordination of care and health transitions to facilitate identification of appropriate interventions for improvement and maintenance of health.
• Utilize a holistic, patient-centered, evidence-based approach to attaining expected outcomes.
• Develop a goal-oriented plan for patients seeking care for health promoti