RN-Ambulatory Population Care Coordinator

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

Embodying Christ's healing love for all people is essential component of the RN Ambulatory Population Care Coordinator for the Physician Clinical Integration Network.  Colleagues in this role will collaborate with at-risk population clients and their primary care providers to provide care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Under general administrative direction, they give patient education related to their illness and planned treatment, provides medication management in collaboration with the primary care provider, and promote patient self-management. Works in partnership with entire healthcare team to manage transitions of care and close gaps in care.

Graduate from an accredited and approved school of nursing accepted for licensure in the state of practice is required. 

Bachelor’s degree in Nursing is preferred. 

Home Health experience is preferred.

Case Management experience is preferred.

Licensed as a Registered Nurse (RN) in the state of practice is required.

Demonstrated problem-solving skills.

Excellent collaboration and team building skills along with excellent communication skills.

Detail oriented with demonstrated high commitment to quality.

Proficient in Excel, Powerpoint, and various electronic medical records.

Demonstrated customer service skills.

Demonstrated time management and priority setting skills.

Strong verbal communication and listening skills.

Excellent organizational skills along with ability to perform work independently with minimal supervision.

Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the at-risk population client's health status.

Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.

Designs an individualized care plan with the client and fosters a team approach to working collaboratively with the client, family, primary care provider, and other members of the health care team to ensure coordination of services.

Reviews the current literature regarding effective engagement and communication strategies, case management strategies, and behavior change strategies and incorporates into clinical practice.

Participates in performance improvement activities.

Standardized education provided with each patient outreach.

Assess and prioritize patient outreaches each day.

Provides consultative activities to assure that medically related social service needs of patients/clients/residents are identified and that the needs are met by the appropriate disciplines.

Coordination of referrals and other community resources.

Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the at-risk population client's health status.

Sets goals with patient, family and treatment team with time frames in context with financial and community resources.

Promotes other Care Coordination programs during outreach to drive referrals.

Serves as liaison between physicians, staff, nursing homes, outside agencies, patients and families.

Communicates with other team members on needed resources.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Reduces the risk of healthcare acquired infections through compliance with current CDC hand hygiene guidelines and facility policies including the wearing of Personal Protective Equipment (PPE), if applicable.  Utilizes standard precautions during patient contact and when handling contaminated materials.  Demonstrates compliance with National Patient Safety Goals.

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline.  Commits to keeping all patient, student or colleague information confidential and maintains excellent interpersonal communication with the health care team colleagues.

Emphasizes a holistic approach to patient care-attending to body, mind, and spirit while upholding ethical principles with patient care and all other aspects of work.  Actively involves the patient and family in decisions about care.  Promotes quality care by participating in organizational councils/committees and/or support of related process.  Documents services provided to patients in the electronic medical record in accordance with policy and requirements. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other