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Description JOB PURPOSE:
Working collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum. Responsible for coordinating a wide range of self-management support and disease registry activities for the clinics entire patient population. Assists in routing patients to complementary support services as well as education and outreach programs.
Key Responsibilities
- Coordinates patient care across the care continuum, being a liaison between patients and their families and clinics, and serving as an advocate for the patient.
Conducts pre-visit chart review of patients including identification of all needed preventive health maintenance, immunizations, and chronic disease interventions. Facilitates the ordering or completion of medically-appropriate interventions before the patient sees a provider. Acts as a liaison with patients and their families to physicians, clinical staff, and other departments. Delegates tasks to RMAs on team and works as a team to deliver pt care. Provides supervision and guidance to RMAs where necessary. Acts as a liaison with hospitalized patients and the clinic. Follows up with patients by phone shortly after hospital discharge. Acts as a liaison with specialty clinics. Facilitates interdisciplinary communication. Proactively acts as a patient advocate, responding to and working to resolve patient concerns. Recognizes and seeks opportunities for program improvement based on patient needs and concerns. Assesses learning needs of patient and significant other to support the patient throughout the care continuum. Facilitates the process of linking patients with community resources. Coordinates discharge information from hospitalists.
- Demonstrates clinical leadership as evidenced by previous work-related activities and work performance.
Applies professional nursing skills in the provision of preventive health maintenance and/or treatment of illness. Demonstrates sound knowledge bases and actions in the decision-making process for designated patient populations. Accurately and legibly documents all patient interactions in the patient record. Types correspondence (memos and letters), statistical forms and procedures and is able to maintain complete patient records while keeping complete patient confidentiality at all times. Acknowledges patients rights on confidentiality issues and follows
HIPAA guidelines and regulations. Works independently to assess and evaluate understanding of disease process, treatment plan, and/or lifestyle changes. Demonstrates positive professional customer service by being respectful of all patients, coworkers, and providers, treating all with equality regardless of their gender, color, race, medical problem, sexual orientation, religion, or socioeconomic status. Demonstrates a positive attitude by smiling and being courteous to all patients, coworkers and providers, making every effort to be non-judgmental with comments and conversation. Documents program-specific outcomes. Proactively continues to educate self to provide quality care and improve professional skills. Additionally, may serve as a subject matter expert (SME) or champion for a select service line or transition of care function. SME serves as a liaison between the Population Health team and related clinical care areas across the system and ensures best practices are maintained. The SME is the Population Health teams primary resource for training, support, troubleshooting and questions related to the condition and/or activity. The SME is also responsible to monitoring and reporting key metrics and team performance on clinical outcomes and clinical effectiveness measures.
- Works with patients and families on patient Self-Management Support.
Setting short and long-term goals for self-management of chronic disease. Addressing medication adherence in patients not meeting outcome goals. Works with patient to create a plan for health behavior change. Makes a plan for follow-up between visits. Provides or arranges needed patient education regarding specific health care skills and general disease concepts. Assists with shared medical appointments. Communicating face-to-face in the office setting, by telephone, or by e-mail.
- Oversees and demonstrates competence in utilizing the disease management database.
Identifies patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate. Identifies patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
- Demonstrates effective organizational skills.
Demonstrates professional, appropriate, effective, and tactful written, verbal, and nonverbal communication with patients, families, medical staff, colleagues, vendors, and other departments throughout the continuum of care to promote continuity of care and services and enhance clinic image. Demonstrates expert practice skills that include flexibility, priority setting, problem solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal/written communication skills. Demonstrates current level of knowledge of various payor regulations. Maintains confidentiality of patient, personnel, and institutional information. Participates effectively as a team member in the clinic being accountable, helpful, and welcoming to co-workers, providers, and patients. Participates in orientation and staff development activities as requested.
- Takes on special assignments as deemed appropriate.
Knowledge, Skills, Abilities
Has an up-to-date knowledge of current trends, nursing practices, and research related to chronic disease states, specifically: diabetes, cardiovascular care, and spine treatment.
Skill and ability to communicate effectively both verbally and in-writing.
Skill and ability to handle multiple priorities and deadlines.
Ability to work as a member of a team.
Skill and ability in Microsoft Office applications.
Qualifications
MINIMUM EDUCATION REQUIRED:
Graduate from an accredited school of nursing.
Minimum Experience Required
Three years of clinical experience in chronic disease states, with demonstrated clinical competence.
Minimum Licensure/Certification Required By Law
Current licensure to practice Nursing in Georgia.
Preferred Qualifications
CCTM: Care Coordination Transition Management.
