CLINICAL CARE COORDINATOR (SURGICAL CLINIC)

Essential Duties, Functions And Responsibilities

• Develops and implements comprehensive care plans with patient, family, team (emergency plan, medical summary, and action plan as appropriate), and evaluates and continually monitors/updates/alters these plans based on patient/family needs and unmet needs, strengths, and assets.
• Captures and reviews patient’s health status through physical assessment and examination, interviewing patient and family member, and reviewing patient's health history.
• Cultivates and supports assigned care & subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan.
• Educates, counsels, supports and provides patient appropriate anticipatory guidance. In a crisis, intervenes or facilitate referrals appropriately.
• Builds care relationships and patient-specific skills among family and team; supports the primary care-giving role of the family.
• Facilitates patient/family access to available medical, psychological, developmental, educational, social, and financial services and supports.
• Serves as the point-of-contact, advocate, and informational resource for family and community partners/payers, including having a close working relationship with the FDIHB Purchase Referred Care Department.
• Serves as a consultant and resource person to FDIHB staff, including physicians, nurses, therapists, pharmacists, dentists, etc. on issues regarding patients and their care.
• Develops and maintains policies and procedures related to the care and care coordination of complex patients with chronic diseases.
• Develops and maintains policies and procedures related to the screening of patients for the presence of complex, chronic medical issues according to relevant standards and guidelines.
• Develops formal referral forms, policies, and procedures that relate to accessing these services and supports.
• Serves as a quality improvement team member; helps to measure quality and to identify, test, refine and implement practice improvements.
• Maintains professional growth and development through seminars, workshops, independent study, and professional affiliations to keep abreast of the latest trends related to patients with chronic disease, throughout the care continuum.
• Attends to specific clinical needs of empaneled complex patients on an as needed basis in the clinic and/or on the inpatient unit. Closely collaborates with the primary care provider (Physician, Advanced Practice Clinician) and the clinical nurses in these instances.
• Provides skilled and comprehensive nursing care to patients as needed.
• Offers outreach and education to the community related to chronic care patients, their issues, their needs, and details regarding the function of the Chronic Care Model in the form of presentations and informational sessions.
• Develops and maintains related educational materials and provides instruction or other learning opportunities to meet the needs of the target audience.
• Utilizes theories and principles of education/learning (age-specific, developmentally and culturally appropriate) to foster the educational development of the target audience.
• Fields queries from the community regarding patients with chronic care diseases and issues related to this patient population.

Mandatory Minimum Qualifications

• Experience: Two (2) years of Registered Nurse experience in a clinical, medical/surgical, acute and/or critical care setting.
• Education: Associate of Science degree in Nursing from an accredited nursing program.
• Licenses: Valid and unrestricted Registered Nurse license in any U.S. State or Territory.
• Certifications: Valid American Heart Association certification in Basic Life Support (BLS) and maintain certification.