POSITION OVERVIEW:
To maintain the day-to-day operations and coordination of the Clinic Care Coordination Program for high-risk patients at Jefferson County Health Center. The Clinic Care Coordinator’s primary role is to assist outpatient departments with services provided to deal with medical, social, psychological, and emotional needs of patients providing continuum of care for patients throughout various health systems. The Clinic Care Coordinator will also serve as a liaison between and among members of the healthcare team and providers to ensure optimal patient care. The Clinic Care Coordinator will collaborate with multiple disciplines, agencies, providers and community resources to access needed care. Will serve as a healthcare educator for patients and staff by utilizing their knowledge and providing, quality improvement and problem solving in the coordination of patient activities.
QUALIFICATIONS:
- Graduate of an accredited school of nursing, with current Iowa RN or LPN license, or Licensed Social Worker
- Minimum of 2 years of nursing care or social work experience
ACCOUNTABILITY:
Reports to Clinic Quality Supervisor
DIRECT REPORTS:
None
POSITION-SPECIFIC REQUIREMENTS:
Transitional Care
- Identifies vulnerable inpatients that are high risk for readmission and coordinates outpatient services.
- Conducts face-to-face visits with patients in healthcare facility or in patient’s home, if applicable
- Weekly phone calls for 4 weeks as needed
- Collaborates with Case Manager-Discharge Planner
- Assists with scheduling follow-up appointments, establishing a local provider, provider orders, set up appropriate local services per patient needs
- Reinforce education and discharge instructions
- Act as liaison between patients, caregivers, support services, specialty providers and local providers
- Other duties as assigned
Chronic Care
- Coordinates outpatient services for vulnerable patients needing support to follow treatment plans and coordination of follow-up care.
- Accepts and follows through with vulnerable patients referred to the program.
- Acts as a resource within the organization and the community regarding health issues.
- Must have knowledge of healthcare practice, quality improvement concepts, patient/family education concepts and theories. Also, must have knowledge of community resources and reimbursement mechanisms.
- Conduct face-to-face visits with patient in healthcare facility or in patient’s home as needed
- Initiates telephone outreach and is available by phone during office hours.
- Work independently and keeps providers and/or nurses informed of patient status.
- Uses all components of Transitional Care Model and nursing process (within scope of practice) including assessment, planning, implementing and evaluating care to meet patients’ needs.
- Provides health maintenance, and medication and disease management education to patients and families/caregivers.
- Collects, organizes, documents, and analyzes data, synthesizing it into understandable information
- Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing.
- Works with outside facilities and agencies on a routine basis, maintaining positive working relationships.
- Must have exceptional customer service supporting patients and their families and provides compassionate care.
- Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient’s primary healthcare provider(s)
- Connects patients with community and other resources.
- Check-in on the patient regularly and evaluate and document their progress.
- Assist patient with securing funding for medical care as needed.
- Accurately participates in medication reconciliation across continuum of care.
- Ability to communicate with small and large groups.
- Attend ongoing training and courses to keep abreast of new developments in health care.
- Other duties as assigned.
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