POSITION SUMMARY

Works collaboratively with multidisciplinary care team across the continuum of care to provide care and disease management to high-risk patients identified in the ambulatory setting, focusing efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness.  Coordinates the discharge planning with the attending physician and assists connecting patient and family with appropriate community resources.  Makes patient & family aware of Medicare/insurance benefits and qualifying factors. Ensures the patient’s personal discharge goal be considered with input from the family.  

Essential Duties

The Care Coordinator will be responsible for the following:

• Uses assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
• Conducts or facilitates targeted outreach efforts to a defined panel of high-risk patients (chronic illness, lack of social support, readmissions, ED visits, etc.) to ensure timely and efficient care delivery across the continuum of care.
• Utilizes technological tools (registries, patient lists, etc.) to manage populations.
• Conducts comprehensive clinical assessments that include disease-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.
• Actively involves the patient and family regarding coordination of their care. Shares this information with the healthcare team, patient, and family.
• Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
• Monitor patient compliance with plan of care. Performs reassessments regarding patient progress toward goals and updates plan of care as appropriate. 
• Ensures care gaps are closed around specialty disease/chronic disease. Coordination: Often serves as primary patient contact for team related to condition. Facilitates access to services.
• Organizes tasks and responsibilities around the patient and family needs. Serves as the liaison with patients and families to physicians and clinical staff.
• Assists in managing transitions of care across care settings, ensuring optimal communication, and planning of care.
• To promote discharge planning services to facilitate a timely discharge to a safe and healthful environment.
• To ensure the right to each patient, to reach her/his highest level of independent wellness through the support of post hospital and community services as needed.
• To carry out discharge planning interventions as ordered by the physicians, implementing them with the individual needs of the patient as a priority, while respecting the patient’s personal beliefs and values. Local agencies will be consulted, and community resources utilized whenever necessary.
• Focuses the plan of care and services on the patient/family needs, preferences and advocacy using multidisciplinary approach.
• Provides facility and community resource information for patient and families to make realistic choices about post-hospital care plan and to facilitate the implementation of the established plan.
• Provides a continual system of communication through documentation and re-evaluation of the patient considering the anticipated needs at the present level of health care delivery and thereafter.
• Provides a consistent method of patient care management, which maximizes the hospital length of stay thereby decreasing the risk of readmissions related to noncompliance and inappropriate utilization of resource.
• Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies.
• Ensure discharge planning policies and procedures are up to date with current regulations and best practices.
• Fill in at clinic and hospital as needed.
• Other duties as assigned.

QUALIFICATIONS & REQUIREMENTS

Education and Experience

• Associate/bachelor’s degree in nursing (Required)
• Minimum of five years’ experience in nursing

• BLS, ACLS, and TNCC or CALS with Trauma Module (Preferred)
• Population Health or ACO experience (Preferred)
• Knowledge and experience using EPIC EHR (Preferred)
• Proficient knowledge and experience using computer applications (Windows, MS Office, etc.)
• Knowledge of external regulations that affect the area of responsibility.

Required Licenses

• Registered Nurse (RN)

Skills, Abilities, and Knowledge

• Knowledge and experience of rules and regulations regarding the medical staff
• Strong oral and written communication skills
• Demonstrates a high degree of commitment to customer service excellence
• Ability to work effectively with internal and external stakeholders, building strong relationships
• Ability to perform tasks both collaboratively and independently
• Maintains confidentiality of information and privacy compliance

Travel

• Minimal travel may be required up to 5%

COMPETENCIES

• Initiative – Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities; Asks for and offers help when needed.
• Judgment – Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Quality – Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Professionalism – Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Safety and Security – Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.
• Teamwork – Balances team and individual responsibilities; Exhibits objectivity and openness to other views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone's efforts to succeed.
• Verbal Communication –Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written Communication – Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

SUPERVISOR RESPONSIBILITIES

• This position has supervisory responsibilities.

PHYSICAL REQUIREMENTS

• This position is subject to sedentary work, exerting up to 15 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involved sitting most of the time. Walking and standing are required occasionally.
• This position is subject to the following physical activities: talking, hearing, and the use of hands, wrists, or fingers in repetitive motions.

Physical Activities

• This position is subject to the following physical activities: talking, hearing, and the use of hands, wrists, or fingers in repetitive motions.

Visual Acuity

• The worker is required to have close visual acuity to perform an activity such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; expansive reading; visual inspection involving small defects, small parts, and/or operation of machines (including inspection); using measurement devices; and/or assembly of fabrication of parts at distances close to the eyes.

Working Conditions

• This position operates in a professional office environment. This role routinely uses standard office equipment.

Johnson Memorial Health Services (JMHS) is an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, JMHS will provide reasonable accommodations to qualified individuals with disabilities and encourage prospective and current employees to discuss potential accommodations with the employer. The above statements are not intended to be an all-inclusive list of job duties, responsibilities, skills, or abilities required to perform this job. Rather, they are intended only to describe the general nature of the position. Johnson Memorial Health Services reserves the right to modify position descriptions as necessary to meet the organization's needs.