The Clinical Case Coordinator II works within the Franciscan Alliance- St. Elizabeth framework of a Patient Centered Medical Home (PCMH). CCC II utilizes a team approach focusing on a continuous partnership with the patient, families, caregivers, physicians, hospitals, and community resources. The CCC II purpose is to promote consistent delivery of quality care, timely access to needed care, teaching and understanding of education and continuity of care across the continuum. Additionally, the CCC II strives to enhance and promote the improvement of overall health of the patient and the community utilizing the most cost effective delivery system. Essential job functions Implements and Utilizes the Care Management Process
Works with ACO Leadership in the design, implementation and evaluation of the PCMH Model
Identifies targeted population within practice site; risk stratifies all members prioritizing needs/direct interventions
Works with PCMH physicians and staff to continuously evaluate process, identify problems and propose process improvement strategies to enhance the Medical Home delivery of care model
Maintains an environment that encourages patient retention and development of customer service/centered care
Ensures assessments, screening, documentation, referrals are appropriate, completed and quality measures met Provides Physician, Patient, Family, Staff and Student Education
Participates in developing and implementing the goal-directed plan of care with patient engagement, which is prioritized, based on specific outcome criteria and evaluated and communicated for effectiveness of care
Available to meet with physicians, assist staff with complex physicians/patients issues
Performs follow up phone calls following a patient care encounter for issues, feedback and follow up needs
Assist with education for patients/family; knowledgeable of tools: use of My Chart (EPIC); A.D.A.M as needed Practices Care Management Competence
Demonstrates competence in advanced care management skills and equipment
Demonstrates commitment to continuously improve care management processes with other healthcare providers
Maintains established safety, environmental, and infection control standards and takes appropriate corrective action for identified infractions
Adheres to Franciscan Alliance employee standards as outlined in employee handbook Care Management Specific Functions
Assumes professional responsibility to maintain current knowledge for regulations, state, federal, private and clinical knowledge necessary to fulfill job requirements
Maintains current knowledge of department standards, is a resource for staff, other departments and members of healthcare team, while promoting management of situations that reduce risk
Demonstrates priority setting ability, problem-solving and organizational skills and completion of essential tasks; as well as participate in meetings, reports, data collection, analysis, recommendations, and other activities that support care management functions
Assume responsibilities as directed during absences to assist with daily operations to ensure efficient workflow
Assists with orientation of new employees, coordinates on-the-job training and ensures standards of performance met before allowing to work without direct supervision
Queries physicians as needed for clarity and complete documentation Knowledge, skills & abilities to assess and respond to the needs of patients and families
Demonstrates knowledge of scientific principles as applied to nursing process with chronic disease management focus.
Demonstrates ability to assess, respond to needs of patients and families coping with the emotional stress of illness.
Demonstrates ability to influence and negotiate individual and group decision-making.
Demonstrates ability to work autonomously and be directly accountable for practice in a fluid, dynamic, and rapidly changing environment and recognize levels of complex patient needs and alert appropriate team members to issues.
Demonstrates leadership qualities of time management; verbal and written communication skills, listening skills and problem-solving, decision-making, priority setting, work delegation, organization and team-building skills with ability to function independently and interdependently as a member of healthcare team.
Demonstrates flexibility in work assignments.
Demonstrates awareness of cultural diversity and demonstrates sensitivity and responsiveness to varying cultural characteristics and beliefs.
Demonstrates general computer knowledge and capability in use of computers.
Demonstrates appropriate conflict resolution, assertiveness, negotiation and collaboration skills. Minimum position qualifications
Education : Graduate of an accredited school of nursing BSN preferred.
Experience : Minimum of three years of nursing experience required. Prefer experience in patient care management i.e.: hospital, clinic, home care.
Licensure/Certification : Current Indiana Registered Nurse license.
Other : Current Indiana Driver's License required and in good standing.
CPR certification required.
Keywords: Clinical Case Coordinator II
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