JOB SUMMARY:

This role coordinates care of the Care Transformation Organization (CTO) assigned Medicare patients within the primary care provider's office. Works with an interdisciplinary team to manage care and coordinate care services attributed to partisan practices. Assess psychosocial needs and functional deficits of the patient and informs providers of changes in the care plan and/or patient's condition. Through an integrated approach, this role completes intake assessments, assists with the treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinating and implementing of treatment referrals. This position plans and organizes community-based services that support the patients' self-management, adherence to treatment plans, and reduction of unnecessary re-hospitalization.

REPORTING RELATIONSHIPS:

Supervised by: Clinical Coordinator or Clinical Manager

Supervision provided to: None

PHYSICAL ENVIRONMENT/WORKING CONDITIONS:

X Sitting

X Standing

X Bending

X Climbing

X Reaching

X Pushing

X Pulling

X Stooping

X Walking

X Lifting

X 0-25 lbs.

26-50 lbs.

More than 50 lbs.

X Working at a computer terminal

Exposure to substantial temperature changes

X Work in confined spaces

Work around high noise levels

Contact with bodily fluids (blood borne pathogens)

N/A

Rarely

X Sometimes

Frequently

Contact with ionizing radiation

X Exposure to infection, biochemical, hazardous waste

X Requires use of protective equipment, including latex gloves

X Requires travel between system locations

This job description identifies the general nature and scope of work to be performed. UM UCH reserves the right to revise all or any part of this job description and to add or eliminate essential job functions at any time. Designation of any job duty as an essential function is not intended as an assurance or guarantee that a team member has any right to perform the particular job duty, except as required by UM UCH.

JOB TASK LIST

1. Care coordination includes: Screen and prioritize patient care needs; Assess physical / psychosocial needs and functional deficits of patients; Provide telephonic guidance, advice and support to patients; Set health improvement / health management goals for patients; Develop and maintain electronic care plan; Conducts home visits as appropriate.
2. Communicates and collaborates regularly with the patient's clinical team, primary care provider, and community-providers (to include home health agencies, adult protective services and patient's family as authorized by patient) on patient needs, concerns, treatment adherence and any changes to ensure seamless continuity of care.
3. The RN is to stay current on area resources and will provide resources to patients when barriers to health care (social / medical) are identified in an effort to prevent unnecessary use of the healthcare system.
4. Maintains accurate timely documentation of actions/services in the appropriate EMR and data collection.
5. Works jointly with the primary care offices, the Comprehensive Care Center, area community partners and population health team members to include social work and pharmacy in an effort to prevent unnecessary hospital admissions, readmissions and emergency department visits.
6. Establishes and cultivates relationships with clients and their families to provide general support and encouragement by attending office visits, telephone outreach and home visits that include medication reconciliation and vital signs as required.
7. Educates patients about chronic diseases, medications/medication management and dietary needs to support the improvement of health conditions and lifestyle changes in an effort to reduce the need for medical intervention.
8. Conducts patient's medication reviews, monitors and evaluates patient biometrics data within the tele monitoring portal and contacts the patient and physician as needed.
9. Provides weekly guidance and care coordination with community health workers, care coordinators and licensed practical nurses by utilizing skills of delegation and continued follow up to ensure safe and appropriate care is being provided.
10. Establishes an effective and appropriate means of communicating and collaborating with providers, team members, and UCH Population Health team to ensure safe and efficient services and continuity of care.
11. Maintains professional development best practices and continuing education requirements for licensure. Staying up to date on population health guidelines and initiatives by participation in relevant educational programs and in-services.
12. Participates in departmental initiatives and process improvement plans in an effort to maximize annual departmental goals.
13. Demonstrates professionalism; competence; and open communication style; high integrity; leads by example, high energy, creativity, diplomacy; and flexibility.
14. Adheres to HIPAA confidentiality rules and regulations.
15. Assists with special projects and performs other duties as assigned.