Key Details
- Department: Care Coordination
- Schedule: Monday - Friday, 8am - 4:30pm
- Hospital: Witham Health Services
- Location: Lebanon, IN
Job Summary
The Care Coordinator coordinates team based care to provide health services to individuals, families and/or their communities through effective partnerships with patients, their caregivers and their physician. Facilitates a shared goal model within and across settings to achieve coordinated high quality care that is patient/family centered.
Minimum Qualifications/Requirements
- Graduate from an accredited school of nursing program; BSN preferred.
- Valid license to practice Nursing in the State of Indiana.
- 3-5 years' experience in clinical or community health settings.
- Previous Care Coordination and/or Case Management experience preferred.
- Demonstrates evidence of essential leadership, communication, education, and counseling skills.
- Proficient in communication technologies (email, cell phone, etc.).
- Effective organizational skills, demonstrates ability to maintain accurate notes and records.
- Previous experience with health IT systems and data reports preferred.
- Previous experience with mobilizing community resources, navigating through the healthcare continuum and working with disparate populations preferred.
- Ability to speak Spanish as a second language preferred.
Competencies/Essential Functions
- Core values consistent with a patient/family centered approach to care.
- Demonstrates professional, appropriate, effective written, verbal and nonverbal communication skills.
- Demonstrates a positive attitude and respectful, professional customer service.
- Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
- Proactively acts as patient advocate, responding with empathy and respect to resolve patient/family concerns. Recognizes opportunities for improvement to meeting patient concerns.
- Demonstrates continual learning skills, effects changes in approach to care based on established evidence based practice.
- Demonstrates professional practice behavior, provides mentoring/coaching of other population health/care coordination team members.
- Cultivates effective partnerships and collaboration with physician providers.
- Demonstrates understanding of use of I.T. resources and patient databases to promote successful/appropriate provider encounters.
- Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.
Duties and Responsibilities
- Provide a coordinated strategic approach to detect early and manage effectively the patient with chronic disease. Establish an effective internal tracking system for identified patients.
- Coach patients/families toward successful self-management of their chronic disease.
- Utilizing tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
- Assess patient and family's unmet health and social needs.
- Provide effective communications to improve health literacy
- Develop a care plan based on mutual goals with the patient, family, and providers (emergency plan, medical summary, and ongoing action plan, as appropriate).
- Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way, and facilitate changes as needed.
- Create ongoing processes for patients and families to determine and request the level of care coordination support they desire at any given point in time.
- Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
- Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
- Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
- Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
- Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
- Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records)
- Facilitate and attend meetings between patient, family, care team, payers, and community resources, as needed.
- Attend all Care Coordination related training and meeting activities.
- Provide feedback for the improvement of the Care Coordination Program.
- All other duties as assigned.
