Complex Care Coordinator
Provides care management and care coordination for adult and pediatric patients, with complex conditions, with complex social needs, education needs and during the transition from hospital discharge to community (Primary Care Provider, Skilled Nursing Facility, Home Health Care, etc.) in the primary care setting, under minimal supervision. Serves in an expanded health care role to collaborate with primary care providers, specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status and decreasing hospital and emergency room utilization. Integrates evidence-based clinical guidelines and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
REQUIRED QUALIFICATIONS: â¢ Associate's Degree in Nursing - For those hired into an RN position after January 15, 2015, it is required to obtain a BSN within 4 years of start date. â¢ Licensed registered nurse in the state of Michigan
PREFERRED QUALIFICATIONS: â¢ Bachelor's Degree in Nursing or higher â¢ Care management experience â¢ Experience as participant in continuous quality improvement â¢ Completion of self-management support training â¢ Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and client education. â¢ Excellent assessment and triage skills. Ability to implement evidence base interventions and protocols.
MAJOR DUTIES AND RESPONSIBILITIES: â¢ Works with team to identify the targeted high-risk population within practice site(s) per population health risk stratification process and discharge lists. Includes patients with repeated social and/or health crises. â¢ Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment. â¢ Collaborates with primary care provider, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated, during the transition period (including 30 days post discharge). â¢ Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care. â¢ Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations. â¢ Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
â¢ Coordinates patient care through ongoing collaboration with primary care provider, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care, which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
â¢ Provides follow-up with high-risk patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: medication reconciliation, primary care provider or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
â¢ Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
â¢ Maintains required documentation and billing for all care management activities based on federal and state billing guidelines. â¢ Works with hospital, practice and Physician Organization/Physician Hospital Organization leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model. â¢ Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
SKILLS AND ABILITIES: â¢ Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, religious beliefs, and cultural ideals. â¢ Demonstrates ability to work autonomously and be directly accountable for practice. â¢ Demonstrates ability to influence and negotiate individual and group decision-making. â¢ Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment. â¢ Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization. â¢ Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
â¢ Support the mission, vision, and values of the organization. â¢ Treat others and their ideas with respect and dignity. â¢ Set a good example for others. â¢ Be an active coach for everyone in the organization. â¢ Maintain the highest standards of honesty, integrity, and communication. â¢ Insist on excellence and be accountable to one another. â¢ Build group cohesiveness and pride through teamwork. â¢ Demonstrate confidence in Munson Healthcare and its workforce in all areas of the community. â¢ Value and promote creativity and the change process. â¢ Be a good communicator and listener; be available and visible. â¢ Develop yourself to your highest potential. â¢ Active participation in Quality Initiatives.