Location: Osgood,IN, USA
Location/Department: Primary Care Milan/Osgood80 hours per pay period - benefit eligibleJob Summary:The Care Coordinator works in collaboration & continuous partnership with chronically ill or high-risk patients & their families, clinic/hospital providers & staff, & community healthcare resources in a team approach to: promote timely access to appropriate care; increase utilization of preventative care; reduce ED utilization & hospital readmissions; increase comprehension through culturally - & linguistically - appropriate education; create & promote adherence to a care plan, developed in coordination with the patient & the patient/family; increase continuity of care by managing relationships with tertiary care providers, transitions-in-care & referrals; increase patients' ability for self-management & shared decision-making; provide medication reconciliation; connect patients to relevant community resources; with a goal of enhancing patient & family health & well-being, increasing patient satisfaction & reducing costs.Supervisory Responsibilities:NoneDuties/Responsibilities:•Uses only approved abbreviations.•Understands patient safety goals & actions taken.•Uses 2 patient identifiers before giving treatments, demonstrates process.•Understands read back of verbal orders/critical lab values & can state process.•Understands procedure to clarify physician orders.•Uses standing orders when indicated.•Accurately calls report to MD as warranted by condition; reports to other providers as needed.•Reports sentinel events or adverse drug reactions or incidents as warranted.•Uses final verification before invasive procedures & can verbalize correct process & documents in EHR.•Reassesses patient in response to changes in condition after intervention as needed & documents in EHR.•Attend all Care Coordinator training webinars & meetings.•Provide feedback for the improvement of the Care Coordination program.•Assist with the identification of high-risk patients (the chronically ill & those with special health care needs).•Work with patients to plan & monitor care; assess patient & family's unmet health & social needs; develop a care plan with the patient, family & providers (emergency plan, medical summary, & ongoing action plan as appropriate); monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way & facilitate changes as needed; create ongoing processes for patients & families to determine level of care coordination support they desire at any given point in time.•Serve as the contact-point, advocate & informational resource for patient, family, payers & community resources.•Facilitate patient access to appropriate medical & specialty providers.•Educate patient & family about relevant community resources.•Cultivate & support primary care & subspecialty co-management with timely communication, inquiry, follow-up, & integration of information into the care plan regarding transitions-in-care & referrals.•Facilitate & attend meetings between patient, family, care team, payers & community resources as needed.Required Skills/Abilities: •Demonstrates professional, appropriate, effective & tactful, written, verbal & nonverbal communication skills. •Demonstrates a positive attitude & respectful, professional customer service. •Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, & follows HIPAA guidelines & regulations. •Proactively acts as patient advocate, responding with empathy & respect to resolve patient & family concerns, & recognizes opportunities for improvement to meeting patient concerns. •Proactively continues to educate self on providing quality care & improving professional skills.•Effectively communicates both verbal & written.Education and Experience:Minimum Associates degree in nursing, Bachelor's degree preferredMinimum of 2 years relevant work experience requiredMust be licensed as a Registered Nurse in the state of IndianaPhysical Requirements: Frequent walking, standing, pushing, pulling, stooping, kneeling, reaching, talking, & use of handsOccasionally may need to lift up to 25 lbs