Care Coordinator RN TRI PC Niagara Falls

Responsibilities

• Identify and stratify the patient population in accordance with the Trinity population care management program.
• Provide proactive care management services to high risk patients with chronic health conditions.
• Reduce the burden of illness, improve compliance with evidence-based clinical guidelines, encourage patient self-management, increase coordination of care, increase the utilization of resources and services across the continuum, and improve patient experience of care while reducing the total cost of care.
• Serve as a change agent for clinical performance and process improvement.
• Provide operational and clinical support to the site Office Manager.

Requirements

• Graduate of an accredited school of professional nursing.
• Bachelor's of Science Degree in Nursing required.
• Current, unrestricted licensure by New York State as a Registered Nurse (RN) required.
• Minimum of (1) year experience as a registered nurse required.
• One (1) year previous case, disease, or utilization management experience preferred.
• One (1) year previous experience in a physician office or ambulatory care setting preferred.

Knowledge, Skill and Ability

• Ability to use an electronic medical record (EMR), patient registry, and run reports from an EMR.
• Effective verbal and communication skills.
• Solid command of the English language.
• Ability to teach, motivate, and influence others.
• Demonstrated ability to work effectively in an interdisciplinary team to facilitate the efforts of the primary care team to assist patients in meeting their goals.
• Demonstrated effective interpersonal relationship and customer service skills.
• Excellent organizational and time management skills.
• Demonstrates understanding of evidence-based guidelines (EBGs) and knowledge of EBGs adopted by the practice.
• Understands and applies performance improvement methods to support the practice in attaining CMP CI Plan goals.
• Ability to convey complex clinical information in a simple, concise way.
• Evaluate patient readiness to change.
• Facilitate patient development of SMART goals in a patient-centric care plan.
• Work effectively with people from diverse cultures and socioeconomic conditions.
• Actively listen to others to understand their perspective and ensure understanding regardless of barriers.
• Critical thinking capability.
• Knowledge of community resources.

Working Conditions

• Occasional local travel between sites may be required.
• May be exposed to infections and contagious diseases.
• Occasional exposure to unpleasant patient elements.
• Contact with patients under various circumstances.
• Exposed to unpleasant elements (accidents, injuries, and illness).
• Subjected to varying and unpredictable situations in a physician office setting.
• Handles emergency or crisis situations.
• Subjected to many interruptions.
• Occasionally subjected to irregular hours, handles absentee replacements on short notice, and flexibility in scheduled working hours/days to meet needs of clinic.
• Multitasking in a fast-paced office environment.
• Occasional extreme heavy physical effort (lifting/carrying 50 lbs. or more).