Under general supervision of the Patient Centered Medical Home (PCMH) Manager, the Clinical Care Coordinator will independently work in conjunction with multidisciplinary teams members involved in the care of patients at the Winslow Indian Health Care Center (WIHCC). Responsible for the delivery of appropriate, timely, and beneficial care for patients by promoting quality and cost-effective health care outcomes in a seamless continuum of care and working within established standards for clinical care coordination, case management principles and advance access principles. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.
Maintains regular attendance and punctuality.
Performs chart reviews for upcoming appointments of their panels.
Track outstanding tests and results, including monitoring consult results for upcoming appointments.
Conduct post-discharge phone calls as follow up for identified high risk patients in their patient panels.
Assist in coordination of care between hospitals. Develops and maintains internal patient care database for continuous tracking and follow up of continuity of care for active management of patients assigned.
Collaborates proactively with all interdisciplinary team members and with a customer-focus to facilitate and maximize patient healthcare outcomes.
Coordinates multi-disciplinary patient care conferences for high risk or complex customers as needed.
Maintains compliance with applicable laws, such as patient confidentiality, abuse reporting, principles of consent and advanced medical directives.
Advocates for the customer/family at the service-delivery level and at the policy-making level fostering the patient’s/family’s decision-making, independence, and growth and development.
Utilizes best practice models to identify, incorporate or develop best practices for panel management.
Collaborates with others to share and establish best practice for clinic and division.
Acts as the resource nurse in the clinic; coordinates with other services lines as needed.
Manages panel acute care and chronic care needs as well as health maintenance, meeting or exceeding clinic expectations for health maintenance standards (GPRA).
Integrates factors related to quality, safety, efficiency, and cost effectiveness in planning, delivering, monitoring and evaluating customer care by promoting the most effective and efficient use of human and financial resources.
Utilizes campus software packages and applications for ordering, scheduling, and tracking customer care.
Assists in tracking referrals and results prior to appointments, in conjunction with WIHCC providers, specialists and close collaboration with the Inpatient and Outpatient RN Case Managers in CHS.
Initiates needed therapeutic measures and other general nursing care.
Participates in department, WIHCC teams and committees.
Participates in the continued development of the role of case management and care coordination in the primary care – advanced access model.
Coaches and mentors all clinical team members to build or enhance capability and competency.
Assists in the implementation of nursing system that supports the mission of the American Academy of Ambulatory Care Nursing (AAACN).
Makes meaningful improvement to services, programs, and processes and/or organizational effectiveness that create new value for customers and employees.
Requires completion of tasks or duties assigned by a supervisor.
Upholds all principles of confidentiality and patient care to the fullest extent.
Adheres to all professional and ethical behavior standards of the healthcare industry.
Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
Possesses cultural awareness and sensitivity.
Maintains compliance with all Human Resources requirements.
Performs other duties as assigned.
Completion of an accredited nursing program and an unrestricted license as a Registered Nurse from any of the 50 states; a Bachelor’s degree or higher in Nursing, will consider ADN with BSN completion within four years from date of hire and with two years of clinical nursing experience or two years as an RN supervisor or management experience. Certificate in case management preferred. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge of standard nursing care for patients throughout the age continuum.
Knowledge of scope of patient care services provided by other clinical service lines and the referral process.
Knowledge of effective teaching processes & principles in planning, providing and evaluating optimum health care.
Knowledge of quality management and improvement processes to comply with internal and external accreditation standards.
Knowledge of general medical procedures and the ability to anticipate complications and the indicated therapeutic interventions.
Knowledge of clinic practices and ability to act as a resource for clinic personnel.
Knowledge of EHR, RPMS, iCare, and other WIHCC software programs in the performance of patient care and coordination.
Knowledge of strong work ethics in the workplace.
Knowledge of basic application of confidentiality.
Knowledge of duties and responsibilities of the position.
Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
Ability to develop, implement, and evaluate care plans.
Ability to provide standard nursing care for patients throughout the age continuum
Ability to promote health care outcomes with currently accepted clinical practice guidelines.
Ability to provide patient education and information on health assessment, disease process, medications, and treatment plans.
Ability to assess patient needs using established clinical guidelines, protocols, and pathways.
Ability to perform job using theory-based nursing practice model, evidenced-based practices, and shared governance in a multidisciplinary team model.
Ability to be dependable in attendance and job performance.
Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
Ability to accept and learn from feedback.
Ability to effectively communicate both in written and verbal.
Ability to provide exemplary customer service at all times.
Ability to interact positively with others and possess great interpersonal skills.
Ability to multitask and perform well under pressure.
Ability to have self-confidence.
Ability to be a great team player.
Ability to accept and learn from supervisor/peer critique.
Ability to be flexible and adaptable to the changing needs of the organization.
While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.
Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.
