Care Coordinator

Bargaining Unit: EAP

Rate of Pay: $73.72/hour + DOE

• Performs the nursing process through assessment, planning, implementation and evaluation of safe therapeutic care to develop patient-entered plan of care to medically complex patients.
• Actively collaborates with healthcare team as an advocate.
• Assists patients through the healthcare system and community by acting as a patient care coordinator.
• Facilitates health and disease patient education through individual teaching and class teaching as indicated.
• Supports patient self-management of disease and behavior modification interventions.
• Assures home monitoring and patient knowledge that is consistent with treatment plan as indicated.
• Coordinates continuity of patient care with internal and external healthcare providers.
• Attends clinic visits, field visits and home visits as indicated to monitor patient progress and assess needs.
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting. 
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon medication reconciliation process.
• Connects to community resources as indicated per Social Drivers of Health assessment.
• Participates on a team for data collection, health outcomes reporting, and clinical audits.
• Demonstrates System Values in performance and behavior.
• Complies with System policies and procedures.
• Other duties may be assigned.

6 months to 1 year relevant experience

• Within 3 months of hire into job

• Self-disciplined, energetic, passionate, and innovative
• Collaborative team member that follows systems and protocols to achieve a common goal
• Highly organized and well-developed oral and written communication skills
• Demonstrates sound judgment, decision-making and problem-solving skills
• Ability to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations
• Confidence to communicate and outreach to other community health care organizations and is aware of community resources
• Demonstrated computer skills
• Proficiency using Electronic Medical Record (EMR)