JOB TITLE: PATIENT CARE COORDINATOR

JOB SUMMARY / OVERVIEW

Connect with patients in the practice, by phone, or in other settings as needed. The primary focus of the role will be to work closely with the high risk patients to support them in coordinating their care, addressing barriers, and helping them become more involved in their health care.

PRIMARY DUTIES

Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify gaps in care and barriers to attaining improved health;

Based on this assessment, and in conjunction with the patient, the patient’s provider, and other members of the care team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the patient;

Coordinate care by serving as the advocate and resource for the patient, their family, and the providers, building effective relationships in the community and across the continuum of care; (local hospitals, home health agencies, senior community service agencies, etc.)

Support the patients and family to ensure safe transitions across the continuum of care;

Assess the patient’s knowledge of their clinical condition and provide education and self-management support based on the patient’s unique learning style;

Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care;

Measure, improve, and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served;

Work directly with providers and clinic staff to support the ACO projects (Annual Wellness Visits, Welcome to Medicare Visits, post hospital and emergency room transition of care calls and scheduling as directed by the CCO) while also identifying patients for care management interventions.

EDUCATION / QUALIFICATIONS

Must be a licensed Practical Nurse (LPN) or Registered Nurse (RN)

Employee is responsible for obtaining and maintaining a BLS certification.

EXPERIENCE / KNOWLEDGE / SKILLS

3-5 years of nursing experience, preferably in care or case management, home health, ambulatory care, community public health, social work, utilization management, or care coordination across multiple settings and with multiple providers

Demonstrate initiative and function independently.

Demonstrate effective communication skills

Experience in working with an electronic medical record.

Familiarity with the community we are serving or commitment to learn and understand through on the ground networking, community assessment, etc.

Knowledge and experience motivating patients and teaching self-management skills

Experience working with vulnerable populations (geriatrics, minorities, behavioral health)

Ability to navigate ambiguity with the aid of structured problem solving techniques

Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion

Comfort with facilitating meetings and coaching other staff

Strong work ethic built on a foundation of proactivity, collaboration, and teamwork

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit, use hands and fingers, handle and feel objects, reach with the hands and arms, talk and hear. The employee is required to stand, walk, climb, and occasionally balance, stoop and kneel. The employee must lift and move 20 pounds or more. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

The employee may have exposure to communicable diseases, bodily fluids, toxic substances, medicinal preparations and other conditions common to a clinic environment.

Job Type: Full-time

Pay: $19.50 - $26.00 per hour

Benefits:

• 403(b)
• 403(b) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• Clinic

Ability to commute/relocate:

• Hutchinson, KS 67502: Reliably commute or planning to relocate before starting work (Required)

Experience:

• nursing: 1 year (Preferred)

License/Certification:

• nursing license (Preferred)

Work Location: In person

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