In this position, the Care Coordinator is responsible for facilitating outpatient case management services for patients in St. Vincent Physician (SVP) clinics. The Care Coordinator generates effective personal plans for high risk participants, such as those experiencing one or more chronic medical conditions, enabling the participant with actionable goals leading to lifestyle management and health risk reduction. The Care Coordinator also provides guidance for Health Coaches within SVP for management of the at risk population to mitigate increasing risk. Job roles and responsibilities emphasize a patient-centered, team-based approach to care and support each team being trained to the highest level of function by the state law.
Essential Duties and Responsibilities
Performs comprehensive assessment of patientsâ?? health needs, including health status and behaviors, level of function, psychosocial situation, and available support systems and determines potential needs;
Establishes care plans in collaboration with the primary care physician and the patient care team;
Provides health education;
Identifies patients at risk for proactive intervention;
Ability to pull and manipulate data to identify risk patients and present information to the care team;
Refers patients to a variety of resources including, but not limited to, nutrition, social work, rehabilitation, behavioral specialist, diabetes education, Healthy Living Workshop, etc.;
Contacts patients who utilize ED or have been hospitalized within 24 hours of discharge to determine the reason for the ED visit or hospitalization and works with patient to develop a plan to avoid those facilities;
Coordinates care for complex cases or those patients seeing multiple specialists;
Maintains up-to-date and accurate documentation of patient assessment and plan provided to the patient to ensure the effective integration of information for use by the health care team to ensure on-going and continued quality of care, in accordance with evidence-based practice, MT Board of Nursing and SVPN policies and regulations;
Analyzes patient care trends and actively seeks out and collaborates with the care team to improve overall quality and efficiency of care;
Uses registry data to identify problems or gaps in services and initiates intervention;
Demonstrates critical thinking for problem solving and prioritization;
Actively participates and leads patient care conferences;
Manages patient panel with physician office staff to identify appropriate patients and measure outcomes;
Collaborates with physicians and office staff;
Pro-actively advocates for patient care issues to ensure that overall quality and type of care is sensitive to each specific patient/familyâ??s needs;
Collaborates with payors and outside agencies to promote a patient centered delivery concept;
Participates in committees and activities related to the development of Medical Home; Accountable Care Organization (ACO), and other insurance carriers;
Collaboratively works with other associates, outside agencies and payors, providers, staff, and managers to coordinate and grow PCMH in SVPN clinic sites;
Responsible for the coordination of PCMH processes including NCQA certification and BC/BS pilot project;
The information above is for summary purposes and is not intended to be a comprehensive list of essential functions.
Minimum of (2) years of clinical nursing experience in an outpatient setting required or (2) yearsâ?? experience coaching individuals with complex and/or chronic conditions
Prior experience in care coordination in a community setting or primary care practice highly preferred
Program development, operations management and supervisory experience preferred
Must have and maintain current MT Driverâ??s license.
Must show proof of insurability and of a clean driving record
Ability to communicate effectively and diplomatically within a multi-functional team
Strong organizational skills and attention to detail
Ability to successfully function in a fast paced, service oriented environment under limited supervision
Experience in understanding and usage of computers as well as the ability to learn applications relevant to the position. Must be able to effectively use Microsoft Office, including Microsoft Excel, Outlook, Meditech HCIS software and web based registry programs
SCL Health is a faith-based, nonprofit healthcare organization that operates eight hospitals, four safety net clinics, one children’s mental health center and more than 190 ambulatory service centers in three states – Colorado, Kansas and Montana. The health system includes 15,000 full-time associates and more than 500 employed providers.