Clinical Care Coordinator

JOB SUMMARY

The Clinical Care Coordinator is an integral member of the office care team.  Provides care management and care coordination for patients that are experiencing a transition of care, undergoing treatment or have moderate to complex illness, while working under minimal supervision. Provides care management and care coordination for adult and pediatric patients with moderate to complex illness, in the primary care setting, with minimal supervision. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience.  Recognizes and demonstrates understanding of patient and family centered care. 

PRIMARY JOB RESPONSIBILITIES

1. Collaborates with patients and caregivers and members of the health care team to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.
2. Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; Empowers patients to manage their health
3. Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population the care coordinator ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
4. Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient's health status. 
5. Serves as an active member of the office-based care team and works closely to support identification and referrals of eligible patients for care management support.
6. Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provide support and education to avoid further readmissions.
7. Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.
8. Maintains the ability to utilize guidelines and standards of care for management of chronicdiseases.
9. Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions.   Clinical work entails:
   1. Coordinates and provides patient education for common patient populations within the office. 
   2. Designs individual plan of care for patients based on evidence-based guidelines.
   3. Fosters a team approach by collaborating/referring patients to supporting members of the care team (Dietician, Diabetes Educator, Pharmacy, etc.) and ensures coordination of services.
   4. Assesses health behavior and disease-specific risks; identifies a plan of action for patients. 
   5. Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient and office education.
   6. Refers selected patients to determined community resources and coordinate with these resources.
   7. Provides patient-specific feedback to providers and clinical team.
   8. Provides face-to-face and telephone interactions with patient population.
   1. Utilizes relevant computer information support including the EMR and any other care management and/or clinical IS systems needed to complete the tasks of clinical care and performance reporting.
10. Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
11. Research and facilitate services for patients outside of their benefits while utilizing community services and resources.
12. Evaluate and manage day to day workflow and adjust as needed to increase efficiencies.
13. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.

DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES

1.  Other duties as assigned

JOB SPECIFICATIONS

EDUCATION

1. Current Michigan license as a Registered Nurse or Licensed Practical Nurse

EXPERIENCE

1. 3-5 years of experience with primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years.
2. Care management experience preferred.
3. Experience as participant in continuous quality improvement preferred.

ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS

These physical requirements are not exhaustive and additional job-related physical requirements may be added on an as needed basis.  Corrective devices may be used to meet physical requirements.

1. Sedentary Work:  Frequently required to stand, kneel and crouch.  On a daily basis may be required to move about, sit, climb stairs and bend.  Is frequently required to lift and carry up to 20 lbs.  May be required to push/pull/carry items between 20-100 lbs.
2. Vision:  Requires the ability to perceive the nature of objects by the eye.  Near acuity:  Clarity of vision at 20 inches or less.  Midrange Acuity:  Clarity of vision at distances of more than 20 inches and less than 20 feet.
3. Motor Coordination:  While performing the duties of the job, it is required to regularly perform functions that include using hand and finger movement, handle or feel objects, be able to use tools or equipment that requires reaching with hands and arms.  Must be able to travel independently throughout the hospital; access patients/families including areas confined by space and/or equipment.
4. Speaking/Hearing:  Ability to give and receive information through speaking and listening.

ESSENTIAL TECHNICAL ABILITIES

1. Proficiency using modern office, computer and telephone equipmentas used by Memorial Healthcare.

ESSENTIAL MENTAL ABILITIES

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.

ESSENTIAL SENSORY REQUIREMENTS

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Able to hear for work-related purposes.

INTERPERSONAL SKILLS

1. Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
2. Required to remain calm when adversity is encountered.
3. Open, honest, and tactful communication skills.
4. Ability to work as a team member in all activities.
5. Positive, cooperative and motivated attitude.