Care Coordinator

Reports to the Manager, Director or Executive Director. Coordinates and manages outcomes of a specific patient population to facilitate achievement of quality, service, and cost. Ensures smooth transitioning of care from inpatient setting to post-care settings, community services, or physician offices. Works collaboratively with other Care Coordinators and interdisciplinary staff, internal and external to the organization. Prepares summaries, reports, and profiles. Identifies and evaluates patient and family educational needs, provides assistance and support for patients and families. Establishes and facilitates effective relationships with physicians, staff, patients and families.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Coordinates patient care within established caseloads throughout the entire continuum of care, spanning each area in which care is provided by:

• Assuring patient has smooth transition from hospital to home to physician's office visit.
• Networking with physicians and other health care providers to assure effective implementation of patients' plans of care and establishment of desired patient outcomes.
• Educating and referring patients with chronic illness to manage conditions.
• Assisting physician as liaison between family and inter-disciplinary team by interpreting the plan of care to patients, families, and other members of the health care team.
• Monitoring patient care and concurrently tracking variances.
• Referring variance trends to Manager/Director/Executive Director or appropriate physician reviewer for review and action.
• Assisting with discharge by assuring coordination of community services, follow-up care, and education.
• Reviewing patient medical records to monitor completeness and accuracy, including medical issues not addressed prior to discharge.
• Coordinating the gathering and reporting of patient outcome information post discharge.

Participates in continuous quality improvement by:

• Compiling and analyzing data to generate reports which accurately represent utilization trends and patterns.
• Making recommendations to appropriate committees to improve overall quality of patient care.
• Preparing summaries and reports for review by the Manager/Director or Executive Director.
• Contributes to closing gaps in care.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other job-related assignments and projects as directed.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience

• The level of knowledge, skills and abilities indicated below are normally acquired through the successful completion of a Baccalaureate Degree in Nursing or related area. A master's degree is preferred. Current RN license in the State of Indiana, minimum three years related clinical experience and experience in educating and managing various chronic illnesses.

Knowledge & Skills

• Requires thorough knowledge of clinical care practices, procedures and techniques required to meet targeted patient population.
• Requires comprehensive knowledge of chronic disease states and managing illness.
• Requires working knowledge of research methodology.
• Demonstrates effective analytical and problem-solving skills.
• Demonstrates proficiency in nursing assessment skills.
• Demonstrates clear, effective communication skills, including verbal, written, and listening skills.
• Demonstrates well developed interpersonal skills necessary to promote and maintain cooperative, courteous, and sincere relationships with patients, family members, physicians, staff, and the public.
• Requires ability to independently prioritize and organize work activities and work effectively under pressure.
• Requires ability to identify and utilize appropriate resources. Demonstrates computer literacy and the ability to effectively use word processing, spreadsheet, and electronic health record and presentation software.

Working Conditions

• Works in various environments including patient care areas with frequent changes in job demands.
• Travel required.
• Clear communication and speaking voice for telephone speaking required.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.