Clinical Care Coordinator (46678)

Under general supervision of the Patient Centered Medical Home (PCMH) Manager, the Clinical Care Coordinator will independently work in conjunction with multidisciplinary teams members involved in the care of patients at the Winslow Indian Health Care Center (WIHCC). Responsible for the delivery of appropriate, timely, and beneficial care for patients by promoting quality and cost-effective health care outcomes in a seamless continuum of care and working within established standards for clinical care coordination, case management principles and advance access principles. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Performs chart reviews for upcoming appointments of their panels.
• Track outstanding tests and results, including monitoring consult results for upcoming appointments.
• Conduct post-discharge phone calls as follow up for identified high risk patients in their patient panels.
• Assist in coordination of care between hospitals. Develops and maintains internal patient care database for continuous tracking and follow up of continuity of care for active management of patients assigned.
• Collaborates proactively with all interdisciplinary team members and with a customer-focus to facilitate and maximize patient healthcare outcomes.
• Coordinates multi-disciplinary patient care conferences for high risk or complex customers as needed.
• Maintains compliance with applicable laws, such as patient confidentiality, abuse reporting, principles of consent and advanced medical directives.
• Advocates for the customer/family at the service-delivery level and at the policy-making level fostering the patient’s/family’s decision-making, independence, and growth and development.
• Utilizes best practice models to identify, incorporate or develop best practices for panel management.
• Collaborates with others to share and establish best practice for clinic and division.
• Acts as the resource nurse in the clinic; coordinates with other services lines as needed.
• Manages panel acute care and chronic care needs as well as health maintenance, meeting or exceeding clinic expectations for health maintenance standards (GPRA).
• Integrates factors related to quality, safety, efficiency, and cost effectiveness in planning, delivering, monitoring and evaluating customer care by promoting the most effective and efficient use of human and financial resources.
• Utilizes campus software packages and applications for ordering, scheduling, and tracking customer care.
• Assists in tracking referrals and results prior to appointments, in conjunction with WIHCC providers, specialists and close collaboration with the Inpatient and Outpatient RN Case Managers in CHS.
• Initiates needed therapeutic measures and other general nursing care.
• Participates in department, WIHCC teams and committees.
• Participates in the continued development of the role of case management and care coordination in the primary care – advanced access model.
• Coaches and mentors all clinical team members to build or enhance capability and competency.
• Assists in the implementation of nursing system that supports the mission of the American Academy of Ambulatory Care Nursing (AAACN).
• Makes meaningful improvement to services, programs, and processes and/or organizational effectiveness that create new value for customers and employees.
• Requires completion of tasks or duties assigned by a supervisor.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.