Clinic RN - Care Coordination Program Supervisor

**Pay**

$47.00 - $55.00 / hour BOE - Medical, Vision & Dental Benefits, 403b plan. EOE

**Shift**

Full Time Monday--Friday 40hrs/week

**Description**

Provides exceptional patient care in a collaborative and supportive clinical environment. Responsible for ensuring patients receive comprehensive, high-quality care, working closely with providers and the interdisciplinary team to meet patient needs. Responsible for not only clinical tasks but also helping to ensure continuity of care through coordination, patient education, and direct care for a variety of patient needs.

**Responsibilities**

Works cooperatively within own department and with other employees in other departments.

Willingly assumes additional responsibility to support the team efforts of own and other departments.

Consistently uses good written and verbal communication.

Show the appropriate care, courtesy and respect to all guests, patients, physicians and other employees that they deserve.

Upholds the highest confidentiality that the hospital requires.

Maintains a positive attitude under the most trying of circumstances.

Always have a good and flexible attitude to changes that take place in the department.

Follows all direction concerning changes and acts accordingly.

Maintains a well organized and clean environment to work at maximum efficiency and promoting good quality standards.

Ability to use own initiative to figure out problems.

Care Coordination / Care Management

• Work closely with healthcare providers and interdisciplinary teams to ensure coordinated, comprehensive patient care. manage care for patients with complex conditions, ensuring that each patient's individual care plan is followed and any gaps in care are addressed. This included monitoring care needs, coordinated follow-ups, and ensuring timely interventions as necessary. Assists with staff development and problem solving.
• Follow and manage a panel of complex patients, ensuring that their care is properly coordinated across multiple settings, including referrals to specialists, follow-up care, and addressing any emerging patient needs/concerns as they arise. Monitor for changes in patient conditions and initiate necessary interventions. Apply appropriate charges for care provided when applicable
• Reach out to patients recently discharged from the emergency room or hospital to schedule follow-up appointments ensuring continuity of care, addresses patient concerns, and supports a smooth transition from acute to outpatient care. Inform patient's care provider of any pertinent patient information or care coordination needs post discharge.

Telephone Triage

• Assess and respond to patient inquiries via telephone, providing appropriate guidance, advice, disposition, and follow-up instructions based on protocol. Ensure Timely and accurate advice is provided and coordinate with the healthcare team to facilitate next steps, including referrals or in-person visits.

Nurse Visits

• Provide direct patient care during scheduled nurse visits (ex: screenings, immunizations, dressing changes, education,m adherence support, diabetes, hypertension, etc.), performing through assessments, administering treatments, and addressing patient needs. You will assess each patient's status and use critical thinking to provide ongoing interventions.

Patient Education

• Educate patients and families on medical conditions, treatment plans, medications, and lifestyle modifications to promote health and wellness. Focus on proactive management of chronic conditions, as well as preventive care. Provide education on advanced care planning, encouraging patients to make informed decisions about their healthcare.

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