The Nurse Care Coordinator will be responsible for monitoring and coordinating the patients identified as needing care management.
This position will supervise the Care Coordination Team and oversee chronic care management, patient care activities, and the coordination of services to meet patients' needs and preferences in the delivery of high-quality, high-value health care.
This position will provide follow up care for complex care or chronic disease conditions, by engaging the patient in the planning process to achieve optimal outcomes in their care, and or assisting with coordination in care services based on priority of need.
Duties and Responsibilities include but are not limited to:
- Development and implementation of effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhance care coordination, chronic care management and integrated care and quality of healthcare services
- Create, implement and maintain documented workflows while actively engaging in process analysis activities and driving process improvement for the care coordination team.
- Supervise Care Coordination Team to achieve optimal outcomes in patient care
- Identify patients for care management by Provider referral or using multiple diagnoses criteria or complexity of care requiring monitoring and assistance or via generated patient registries, Managed Care Organizations, E.R. & hospitalization lists, behavioral health or nursing staff.
- Conduct timely patient outreach/engagement activities, via telephone, direct
- mailing or face-to-face, for new and established patients to schedule appointments as needed for care planning etc.
- Track, monitor, and schedule follow up appointments for patients recently discharged from the hospital or ER.
- Engage patients & Providers in goal setting and establish the care planning process.
- Create, monitor, follow up and share completed care plans as needed. Ensure that documentation is completed in EHR.
- Provide timely updates to Providers when encountering barriers or request care conference to assist with identifying problems encountered in reaching goals and provide feedback on progress as well.
- Assist patients with transitions to care, navigating health care services and linkage to community resources in collaboration with care team.
- Regularly collaborate, coordinate, and communicate with care team member(s) to resolve any outstanding patient care related items (i.e. care gaps; outstanding referrals; patient paperwork etc.).
- Completes and submits data collection and reporting for specific clinical quality measures.
- Assist with closing the loop on outstanding referrals, lab results, patient documents and consult reports by following up with patients, specialty providers, hospitals, health plans, community agencies, etc.
- Acts as a resource to the care team and other staff members on the collection and management of population health, data, patient outreach, tracking of patient progress, and generation of reports.
- Monitors clinical quality measure outcomes and identifies opportunities for improvement.
- Produce, maintain and input timely, accurate, and thorough documentation of all communication with patients within the EHR.
- Maintain medical records by adhering lo HIPPA guidelines when handling patient information and sensitive documents.
- Implement and maintain department's process for tracking all outreach efforts made (i.e. appointment scheduling).
- Timely and accurate completion of all care coordination tasks and assignments by deadlines.
- Maintain professionalism always when communicating with patients, staff members, and external agencies.
- Adhere to all policies, procedures, and protocols of the agency and department procedures.
- Participate in Patient Centered Medical Home (PCMH) and quality improvement (QI) related committees and activities
- Participates in clinical supervision.
- Participate in chart audits as needed.
- Attend meetings and trainings as scheduled.
- Participate in clinical and administrative huddles as assigned.
- Triage; provide direct care within scope of licensing
- RX refills
- Develop and implement workflows and KPIs
- Develop and implement systems
- Develop and implement policies and procedures as needed
- Perform other duties as assigned.
- Graduate of an accredited Nursing Program/School
- Valid in the state of Illinois; RN license preferred
- Current BLS certification
- Valid driver’s license and insurance
- At least 1 year of experience in working directly with electronic health records (EHR);
- Experience in an ambulatory selling or prior work experience in a clinic setting doing referral care coordination or similar nursing duties.
- Must be detailed oriented, organized and have the ability to work in a fast-paced environment. Must possess excellent customer services skills.
- Position requires computer literacy to perform job duties/responsibilities
- Must be willing and able to work all CCHC/multiple locations and work a varied schedule to accommodate the needs of CCHC and our patients