Wage range that the company expects to pay: $3,076.92 - $3,392.31

SUMMARY

Under the direction of the Associate Director of Nursing, the RN Care Coordinator ensures care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient, and readmission visits. The RN Care Coordinator ensures utilization of team-based, holistic, patient-centered, evidence based approach to identify patient-centered goals and develop outcomes to improve the health status of patients served by Community Health Centers of the Central Coast. The RN Care Coordinator serves as a clinical liaison, facilitator, advocate, and collaborator in a multidisciplinary care team across the continuum of care to ensure complex disease management interventions to high risk and post discharged patients are acted upon. The RN Care Coordinator is dedicated to providing support to staff in the field and is responsible for supervising Hospital Discharge and ER Follow-Up Coordinator and Patient Navigators.

It is the primary purpose of CHCCC to provide the highest quality of total care possible to the patient population it serves. Such a level of quality depends ultimately on the staff's desire and ability to work together, individually, and as a team. The employee is expected to be professional, punctual, maintain regular attendance, cooperative, organized, and enthusiastic at all times.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Additional duties may be assigned with or without prior notice.

Conduct intake assessment, needs assessment, treatment planning, and reassessment services.

Provide day-to day support, supervision, and performance reviews for Hospital Discharge and ER Follow-Up Coordinator and Patient Navigators.

Reviews patient cases with Hospital Discharge and ER Follow-Up Coordinator and Patient Navigator and provides advice, direction, and support as needed.

Organizes or leads Hospital Discharge and ER Follow-Up Coordinator and Patient Navigator training sessions.

Provides clinical supervision to Hospital Discharge and ER Follow-Up Coordinators and Patient Navigators.

May meet with client along with Patient Navigator after primary care physician appointments to review and update care plan.

Screen clients for eligibility for direct and support services and refer clients to needed services, such as mental health, housing, crisis, and employment assistance.

Facilitate Care Team meetings with Hospital Discharge and ER Follow-Up Coordinators, Patient Navigators and health care providers to discuss client Care Plan and share information regarding referral sources.

Document client services in medical records.

Establish and retain client referral systems from care coordination systems.

Maintain documentation of all client encounters and complete reporting requirements according to organization standards.

Track client information, schedules, files, and forms in a confidential manner.

Initiate outreach and missed appointment procedures, as per CHCCC policy.

Monitors medication management as directed by clinician and within scope of practice.

Attend and represent the organization at professional conferences, in-service trainings, and meetings at the request of or with the approval of supervisor

Conduct quality assurance and monitoring activities for service delivery and documentation

Oversee the development of Coordination of Care as identified by regulatory and accrediting agencies.

Ensure compliance with administrative, legal and regulatory requirements of Health Plan contracts and Government and Accrediting agencies.

Patient safety: Accountable to promote an organizational culture of safety and ensure appropriate patient safety standards and guidelines are followed consistently in the delivery of health care to patients, including but not limited to Healthcare Effectiveness Data and Information Set (HEDIS), The Joint Commission (TJC), National Committee of Quality Assurance (NCQA), Patient Centered Medical Home (PCMH), and Uniform Data System (UDS).

Manage and resolve human resources related situations, employee and department safety and risk management issues; advises on appropriate corrective action and development opportunities.

Ensures the performance and productivity of all Care Coordination team members are evaluated on a regular basis throughout the year and annually.

Ensure that care coordination related to risk management, reimbursement, financial management and other administrative functions are incorporated into operational systems.

Monitor health outcomes related to coordination of care.

Maintains high quality of care by Care Coordination staff through continuous improvement of standards and protocols.

Collaborates with Human Resources to select, orient and train staff, and ensures all staff members are trained in care coordination functions based on job descriptions.

Stays current with state, federal and payer regulations/requirements and updates professional standards for nursing related to care coordination.

Collaborate with other services in developing and implementing innovative models and best practices, emphasizing service improvement and cost reduction.

Supports services that achieve a high level of customer service satisfaction with emphasis on service and innovation.

Participates in patient population management as it relates to clinical services while taking into account cultural diversity and local resources.

Participates in the team member's care coordination by providing follow up phone calls post hospital discharge. Assists the patient with follow up appointments within the recommended time frames and gather data from recent hospital admissions to facilitate follow up.

Understands the role in self-management support and has the ability to refer to a licensed clinician when clinical judgement is in question.

Develop communication skills with all members of the team both internal and external, by first being a patient advocate and use the available resources to facilitate care. Coordinate with the Care Team (PCP, RN, Patient Navigator, Health Educator, LCSW, other nursing staff, ie CMA/RMA, and/or Medical Director) to ensure appropriate services are arranged for the patient in order to improve health outcomes.

Understand the role in the quality improvement process, which may include meetings, data collection and charge auditing. Use Evidence based practice guidelines to assist with disease management.

Must demonstrate strong understanding of cultural competency with the target population.

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served (infants, pediatrics, adolescents, adults or geriatrics).

Demonstrates knowledge of domestic violence, child and dependent abuse protocols.

Demonstrates adherence to and observes all safety policies and procedures, inclusive of infection control rules and regulations.

Maintains and adheres to confidentiality, and privileged communications (patient, employee, and corporation).

SUPERVISORY RESPONSIBILITIES

Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, training employees, planning, assigning and directing work, appraising performance, rewarding and disciplining employees, addressing complaints and resolving problems.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

Graduation from an accredited School of Nursing. Associate Degree in Nursing required; BSN preferred. Minimum five (5) years of nursing experience with a minimum of two (2) years in care coordination/case management experience. Knowledgeable about Federally Qualified Health Centers and Value Based Care. Demonstrates strong interpersonal skills. Demonstrates knowledge of Nursing Practice, TJC, and other local, state and federal agencies.

LANGUAGE SKILLS

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

MATHEMATICAL SKILLS

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

COMPUTER SKILLS

Experience with word processing, spreadsheets, email, and keyboarding required. Ability to learn EHR systems.

CERTIFICATES, LICENSES, REGISTRATIONS

Possession of current, valid, California Driver's License (Class C). Required to maintain current, valid, unrestricted RN license issued by the State of California Board of Registered Nursing.

Current CPR (BLS) certification issued by American Heart Association required. If employee does not have a current CPR certification at time of hire, then employee has 30 days to become certified. Changes to CHC’s CPR Policy will supersede this.

OTHER REQUIREMENTS

Required to pass a criminal history background check and drug screen upon hire. Annual health examination; annual Tuberculosis skin test clearance or chest x-ray; proof of immunity to MMR, Varicella, and Hepatitis B; proof of Tdap vaccine; during current flu season, must provide proof of influenza vaccine or a signed declination form. If declined, a flu mask is mandatory during flu season. Health screening requirements are subject to change based on CDC recommendations and federal, state, and/or local public health ordinances.

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 use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to sit. The employee is occasionally required to stand and walk. The employee must regularly lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing 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 frequently exposed to moving mechanical parts. The employee is occasionally exposed to risk of electrical shock. The noise level in the work environment is usually moderate.

Must be willing to have a flexible work schedule that may include evenings/weekends, and travel as needed.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified.