Nurse Care Coordinator

About the Role

Under the general supervision of the Manager of Population Health & Care Coordination, this position coordinates clinical care, educates, advocates, and serves as the health navigator for patients in the Huggins Hospital Medical Practices. Additionally, the role involves assistance with data collection, analysis, and reporting.

Responsibilities

• Participates in Patient-Centered team meetings.
• Engages in data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to Patient-Centered Care Coordination initiatives.
• Facilitates health and disease management education.
• Supports patient self-management of disease and behavior modification interventions.
• Provides comprehensive preventative wellness exams.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
• In collaboration with the Primary Care Provider (PCP), manages high-risk patient care, including patients with multiple comorbidities or those at high risk for hospital readmission.
• Promotes clear communication among the care team and with treating clinicians to ensure awareness of patient care plans.
• Works with the Population Health Manager and IT on care opportunity reports to identify and address preventative care needs.
• Maximizes opportunities for quality incentive payments from governmental and private payers related to population health and chronic care management.
• Provides data analytics and reporting for population health and disease management.
• Participates in quality review, performance improvement, and medical practice patient satisfaction improvement initiatives.

Organizational Expectations

• Attendance: Comes to work daily, on time, and completes scheduled shifts.
• HIPAA: Facilitates the maintenance of patient confidentiality.
• Internal Communication: Contributes to positive team performance and a culture of service excellence through effective communication, active listening, and respect.
• Interpersonal Relationships: Maintains appropriate relationships with staff, patients, and visitors; works collaboratively with other departments.
• Safety: Practices workplace safety daily.
• Employee Engagement: Actively participates in hospital Service Excellence initiatives and trainings.
• Attends and participates in a minimum of 50% of department staff meetings and reviews 100% of department staff meeting minutes.
• Completes all required annual education on or before the due date.

Skills and Abilities

• Minimal physical effort required, with occasional light lifting to a maximum of 25 pounds; stooping; and use of fingers for typing or similar tasks.
• Ability to effectively manage considerable mental stress.
• Ability to express or exchange ideas through spoken communication.
• Ability to receive detailed information through oral communication.
• Ability to communicate effectively with co-workers and convey information clearly and accurately.
• Familiarity with computers and other business machines.

Qualifications

• Completion of an RN or LPN program.
• One year of office experience preferred.
• Active NH RN or LPN license.
• BLS (Basic Life Support) certification required.