Ambulatory Care Coordinator
Dimensions Health Care System - Cheverly, MD

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Associate's Degree
  • Healthcare Provider CPR required
  • Maryland State Certification Required
  • RN Required
  • 3-5 years experience required
  • POSITION SUMMARY

    To assess and identify patient needs to ensure that safety and high quality care is provided through nursing interventions, education, patient advocacy and coordination of services within an outpatient care setting.

    Principal Duties : Population Health

    1. Facilitates patient care services by managing and individualizing care for patients and their families.

    2. Identifies patients overdue for visits, labs, or referrals and arranging for follow up services as appropriate.

    3. Identifies patients not meeting clinical goals, (for example: BP control or glucose control, anticoagulant therapy) and arranging for follow-up services by protocol or as appropriate.

    4. Creating patient, physician, and clinic level quality performance reports.

    5. Conducts pre-visit chart review of patients including

    a. Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.

    b. Per protocol, initiate interventions before the patient sees a provider.

    c. Completes pre-visit forms or initiates office visits forms to communicate the review to the provider.

    6. Works with patients and families on Self-Management Support including:

    a. Setting short and long-term goals for self-management of chronic disease.

    b. Addressing medication adherence in patients not meeting outcome goals.

    c. Works with patient to create an individualized plan for Health Behavior Change if deemed necessary.

    i. Assessing and working on the patient’ readiness to change, the importance of change, and confidence in ability to change.

    ii. Helping the patient to identify and overcome barriers.

    d. Makes a plan for follow-up between visits

    Required : Current Maryland in good standing as a Registered Nurse.

    Preferred: BSN

    3-5 years experience

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