JOB SUMMARY
The Nurse Care Coordinator will utilize care coordination, case management, and resource management with the purpose of improving the patients health, reducing healthcare costs, and improving the patients healthcare experience. The Nurse Care Coordinator will collaborate with the patients Primary Care Provider, the NOTCH clinics, outside entities, and community health partners to help the patient achieve their healthcare goals. The Nurse Care Coordinator will focus on medical, mental health, substance use, and social determinants of health. The Nurse Care Coordinator will use EMR functionality, NOTCH Partnerships, and referrals to identify high risk/high need patients,
ESSENTIAL DUTIES AND RESPONSIBILITIES
Interacts with patients and members of the care team to provide a range of care services. Specific duties and responsibilities include:
- Act as the NOTCH liaison to 3rd party payers and be responsible for medication authorizations
- Scan and route incoming documents to the appropriate NOTCH employees
- Track diagnostic imaging orders
- Perform transition of care phone calls
- Medication reconciliation
- Collaborate with community partners including but not limited to: home health, designated agencies, skilled nursing facilities, long term care facilities, assisted living facilities, Age Well, Support and Services at Home (SASH), and hospitals
- Participation in NOTCH Patient Centered Medical Home initiatives
- Patient education
- Disease management support
- Manage a caseload of patients
- Engage patients in self-management action planning
- Provide health coaching
- Assist patients with social determinants of health, including but not limited to: housing, food, and transportation to medical appointments
- Update the medical record including medications and medical history
- May execute organization approved standing orders per written procedure
- Coordinate care with specialists and external disease management organizations
- Comply with all documentation requirements, including progress notes, computer data entry, releases of information, treatment and case management plans
- Participate in Quality Improvement projects under the direction of the Care Coordination Team Manager. Participation may include: participating in a new process or change, providing feedback to the tests of change, and providing suggestions for the next tests of change
- Assesses own educational needs in terms of knowledge necessary to the job position and works with the supervisor to create a professional development plan to address knowledge gaps
- Participate in training sessions
- Participate in community events
- Conducts home visits for care coordination, case management, and duties within the scope of practice as determined by the Vermont State Board of Nursing
- Performs other functions or duties as assigned
KNOWLEDGE, SKILLS AND ABILITIES
- Strong written and verbal skills
- Good time management, organizational, and problem solving skills
- Ability to present in a professional manner benefiting the organization
- Willingness to work flexible hours
- Ability to seek supervision when needed or appropriate
- Ability to work as a member of an interdisciplinary team and in an interagency collaboration
- Strong interpersonal skills (proficiency in interviewing, basic negotiation, and mediation)
- Strong computer skills (Microsoft Office Word, Excel).
EDUCATION
Associates or Bachelors Degree in Nursing preferred
EXPERIENCE
Three years experience in clinical setting preferred
CERTIFICATE/LICENSE
Licensed Practical Nurse or Registered Nurse
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.
While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or finger, handle, or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl.
The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.
The noise level in the work environment is usually moderate.
MACHINERY AND EQUIPMENT USED
Personal computer and printer, copier, calculator, telephone, and facsimile machine