Ambulatory Care Coordinator, Registered Nurse

Company Description

Located in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) will provide improved access to primary and ambulatory care services, and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George’s County residents.

Job Description

POSITION SUMMARY

To assess and identify patient needs to ensure that safety and high quality care is provided through nursing interventions, education, patient advocacy and coordination of services within an outpatient care setting.

Principal Duties:

Population Health

1.   Facilitates patient care services by managing and individualizing care for patients and their families.

2.   Identifies patients overdue for visits, labs, or referrals and arranging for follow up services as appropriate.

3.   Identifies patients not meeting clinical goals, (for example: BP control or glucose control, anticoagulant therapy) and arranging for follow-up services by protocol or as appropriate.

4.   Creating patient, physician, and clinic level quality performance reports.

5.   Conducts pre-visit chart review of patients including

a.   Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.

b.   Per protocol, initiate interventions before the patient sees a provider.

c.   Completes pre-visit forms or initiates office visits forms to communicate the review to the provider.

6.   Works with patients and families on Self-Management Support including:

a.   Setting short and long-term goals for self-management of chronic disease. b.   Addressing medication adherence in patients not meeting outcome goals.

c.   Works with patient to create an individualized plan for Health Behavior Change if deemed necessary.

i.   Assessing and working on the patient’ readiness to change, the importance of change, and

confidence in ability to change.

ii.    Helping the patient to identify and overcome barriers.

d.   Makes a plan for follow-up between visits

e.   Provides or arranges needed patient education regarding specific health care skills and general disease concepts.

f.   Provides health care advice through telephone calls or the Internet, if applicable.

Coordination of Care

1.   Assists as liaison with patients and their families to physicians, clinical staff, and other departments.

2.    Acting as a liaison with hospitalized patients and the clinic. Following up with assigned established clinic/office panel patients by phone shortly after hospital discharge or emergency room visit.

3.   Proactively acts as patient advocate, responding to and working to resolve patient concerns.

4.   Providing a link to community resources collaborately with social worker/case manager

5.   Involvement in Performance Improvement activities:

a) Communicates and coordinates with the healthcare team (including management, social worker and providers) in the development of tools for optimal patient outcomes and report findings.

1.   Ensures the smooth and timely flow of patients within the clinical area responding to high volumes of patients in short-term time spans.

2.   Demonstrate, understand and perform triage activities for all walk-in patients and medical phone inquiries; using reasonable and astute clinical judgments in order to expedite the appropriate care and treatment of patients.

3.   Provides working oversight and delegates tasks to licensed practical nurses, and non-licensed medical staff.

4.   Support and ensure accuracy of LPN/Medical assistant who obtain initial information from patients (i.e.: vital signs, symptoms, and complaints) through interviewing patients and reviewing documentation.

5.   Provide nursing care based on physician and mid-level provider orders, to meet the needs (physical, mental, and emotional) of patients.

6.   Documents patient’s response in medical record and ensures appropriate patient consents and authorizations are obtained all medical treatment

7.   Maintain universal precautions and infection control practices.

8.   Prepare patients for examination and assist physician upon request.

9.   Be able to assess patient condition, recognize adverse signs and symptoms, and react swiftly in emergency situations.

10. Administer medications per facility protocols, as prescribed by provider

11. Perform a range of nursing procedures, including dressing changes, suture removal, oxygen administratio