Coordinator, Patient Care - Metro Nashville Public Schools Onsite Clinics

Discover Vanderbilt University Medical Center:  Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health is committed to an environment where everyone has the chance to thrive and where your uniqueness is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

D2E Solution Design

Job Summary:

Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system.

.

Hours:

• Monday-Friday | 8:30a-4:30p

​About MNPS Onsite Clinics: 

• The MNPS Employee & Family Health Care Centers are operated by Vanderbilt Health and staffed by an interdisciplinary team that works together to provide compassionate, whole-person care and health guidance to MNPS and Metro Government employees and their family members. There are five locations across Davidson County. Our board-certified nurse practitioners and physician assistants provide full-spectrum primary care — performing exams, diagnosing and managing both acute and chronic conditions, and prescribing medications when needed. 

Core Duties:

• Plan, support and facilitate group medical visits (GMVs)
• Assist with Lifestyle Medicine program design
• Lead the MNPS Patient Advisory Group 
• Support Whole Person Care initiatives 
• Collaborate with providers and staff across clinic locations 
• Work directly with the MNPS Medical Director on programs, research, and initiatives 
• Work closely with the Whole Person Care Navigation team 
• Data collection (Excel, Epic slicer dicer. REDCap)

Preferred (not required) Skills and Certifications: 

• National Board Certified Health and Wellness Coach (NBHWC) 
• American College of Lifestyle Medicine Certification (DipACLM) 
• Experience with or strong interest in Lifestyle Medicine, population health, employer/employee health and wellness 
• Program / project management experience
• Complex case management experience
• PCC Role
  Supports Whole Person Care initiatives and Lifestyle Medicine programs for MNPS employees and members that focus on preventing and treating chronic disease through lifestyle interventions.  

Key Responsibilities:

• Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
• Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
• Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
• Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
• Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
• Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning n